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By signing this document with an electronic signature, I agree that such signature will be as valid as handwritten signatures to the extent allowed by local law.

   

KNOW YOUR CLIENT (KYC)
APPLICATION FORM
(FOR INDIVIDUALS ONLY)
Please fill in ENGLISH

A. IDENTITY DETAILS (PLEASE SEE INSTRUCTIONS)

1. Name of Applicant
(Please write complete name as per Certificate of Incorporation / Registration. Please do not abbreviate the Name).

2.

3. Country of Issuance

4. Country of Residence

5. Expiration date

* Please provide two forms of ID. See requirements for documents.

B. ADDRESS AND CONTACT DETAILS (PLEASE SEE INSTRUCTIONS)

1. Address for Correspondence

Country

State/Province/Region

City/Town/Village

Address (Street and building, apartment, or other structure)

Zip/Postal Code

2. Contact Details

Telephone (if applicable)

Mobile (if applicable)

Email (if applicable)

3. Proof of address to be provided by Applicant. Please select ANY ONE of the following valid documents and attach documents.


*Not more than 3 Months old.

4. Is Registered Address different from above?

C. COLLATERAL AND BROKERAGE INFORMATION

1. Exchange where stock is traded:

2. Stock Symbol

ISIN

3. Number of shares to be pledged

4. Name of Brokerage Firm

5. Address of Brokerage Firm

6. Account Number

7. Are the shares completely unrestricted?

8. Are you using securities of same Issuer to obtain loans from other Lenders?

9. Does Borrower have same shares of same Issuer pledged to any other Lender?

10. Planned use of proceeds:

D. BANKING INFORMATION (PLEASE SEE INSTRUCTIONS)

1. Name of Banking Institution

2. Account holder's name

3. Account Number

4.

E. ADDITIONAL INFORMATION

1. Is the Borrower an affiliate entity?

2. Total percentage of shares owned of Issuer:

3. How did you acquire these shares?

4. Are you being represented by legal counsel in this transaction?

5. Describe all lawsuits, arbitrations, claims, and demands for damages filed by or against you within the last two (2) years, including their current status:

6. Describe any felony indictments and/or convictions that have been brought against you, if any, including without limitation, indictments or convictions that refer, relate, or pertain to any securities laws, rules, or regulation in any jurisdictions within the past five (5) years:

7. Within the past five (5) years, have you been fined, suspended, or censured by any regulatory agency, stock exchange, or securities trading platform?

8. List all the secured and unsecured personal loans, procured within the past five (5) years, that have defaulted. For each such loan, describe the circumstance the default:

INSTRUCTIONS / CHECK LIST FOR COMPLETING KYC FORM

A. IMPORTANT POINTS

  1. Copies of all the documents submitted by the applicant should be self-attested and accompanied by originals for verification. In case the original of any document is not produced for verification, then the copies should be properly attested by entities authorized for attesting the documents, as per the below mentioned list.
  2. If any proof of identity or address is in a foreign language, then translation into English is required. Name and address of the applicant mentioned on the KYC form, should match with the documentary proof submitted.
  3. If correspondence and permanent address are different, then proofs for both have to be submitted.
  4. Sole proprietor must make the application in his individual name and capacity.
  5. In case of Merchant Navy NRI’s, Mariner’s declaration or certified copy of CDC (Continuous Discharge Certificate) is to be submitted.
  6. Politically Exposed Persons (PEP) are defined as individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States or of.
  7. Governments, senior politicians, senior Government/judicial/military officers, senior executives of state owned corporations, important political party officials, etc.

B. PROOF OF IDENTITY (POI): List of documents admissible as Proof of Identity:

  1. Two forms of ID are a requirement. One form of ID must be a passport with a clear photo.
  2. A second form of ID may be one of the following: ID Card, Driver’s License, Military ID, Voter ID Card, or identity card/ document with applicant’s Photo, issued by any of the following: Central/State Government and its Departments, Statutory/Regulatory Authorities, Public Sector Undertakings, Scheduled Commercial Banks, Public Financial Institutions, Colleges affiliated to Universities and Credit cards/Debit cards, with personal photo, issued by Banks.

C. PROOF OF ADDRESS (POA): List of documents admissible as Proof of Address:
(*Documents having an expiry date should be valid on the date of submission.)

  1. Voters Identity Card/Registered Lease or Sale Agreement of Residence/Driving License/Flat Maintenance bill/Insurance Copy.
  2. Utility bills like Telephone Bill (only land line), Electricity bill or Gas bill - Not more than 3 months old.
  3. Bank Account Statement/Passbook - Not more than 3 months old. Self-declaration by High Court and Supreme Court judges, giving the new address in respect of their own accounts.
  4. Proof of address issued by any of the following: Bank Managers of Scheduled Commercial Banks/Scheduled Co-Operative Bank/Multinational Foreign Banks/Gazetted Officer/Notary public/Elected representatives to the Legislative Assembly/Parliament/Documents issued by any Govt. or Statutory Authority.

D. PROOF OF CURRENT BROKERAGE STATEMENT (POCBS):

  1. A copy of brokerage statement clearly indicating possession of pledged shares needs to be included:
    a. Document must be no older than 3 months
    b. Statement period and end date must be clearly visible
    c. Account number, account holder(s) name(s) and addresses must be included
  2. Contact Information for financial professional managing account must be supplemented. Firm name and contact information must be supplemented if not visible on statement.

E. PROOF OF RECEIVING BANK (PORB):

  1. A copy of current bank statement must be submitted:
    a. Document must be not older than 8 weeks
    b. The banking institution’s name must be clearly visible
    c. Statement period and end date must be clearly visible
    d. Account holder(s) name(s) and addresses must be included
    e. Account number and ABA/SWIFT must be highlighted

DECLARATION

I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to inform of any changes therein, immediately. In case the above information is found to be false or untrue or misleading or misrepresenting, I am/we are aware that I/we may be held liable.

Place:

Date:

Person 1:

 
Authorized Person/Title

 
Signature

 
Initials

Person 2: