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RASHMIKANT SAHOO
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0% found this document useful (0 votes)
37 views5 pages

eSignDocument

Uploaded by

RASHMIKANT SAHOO
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

Know Your Client (KYC)

Intermediary
Application Form (For Individuals Only) CDSL VENTURES LIMITED
Logo
….Exploring New Horizons

Please fill the form in ENGLISH and in BLOCK letters

Fields marked * are mandatory Application Number:


+
Fields marked are pertaining to CKYC and mandatory only if processing CKYC
also Application Type*: 

New KYC  Modification KYC
KYC Mode*: Please Tick (✓)

Normal EKYC OTP EKYC Biometric Online KYC Offline EKYC ✔ Digilocker

1. Identity Details (please refer guidelines overleaf)


PAN* DGEPS3299N Please enclose a duly attested copy of your PAN Card
____________________________
MR RASHMIKANTA SAHOO
Name* (same as ID proof)
Maiden Name+ (if any)
Fathers/Spouse’s Name* MR SUKANTA KUMAR SAHOO

Date of Birth* 25/11/1984

Gender* ✔ Male Female Transgender


Marital Status* Single ✔ Married Recent passport size
Nationality* ✔ Indian Other Applicant Photo

Residential Status* ✔ Resident Individual Non Resident Indian


Please Tick (✓)
Foreign National Person of Indian Origin+
Cross Signature across photograph

(Passport mandatory for NRIs and Foreign Nationals. PIO selection is only for CKYC and not for KRA KYC.
Select NRI or Foreign National based on Nationality of the individual)

Proof of Identity (POI) submitted for PAN exempted cases (Please tick)
A — Aadhaar Card XXXX XXXX __ __ __ __
(Expiry Date)
B — Passport Number
C — Voter ID Card
(Expiry Date)
D —Driving License
E —NREGA Job Card
F — NPR
Z —Others (any document notified by Central Government)

Identification Number
2. Address Details* (please refer guidelines overleaf)
A. Correspondence/ Local Address*
Line 1* SUKANTA KUMAR SAHOO, 21, SIDHESWARPUR, HIGH SCHOOL

Line 2 ROAD, SIDHESWARPUR, 754100, CUTTACK, ODISHA,

Line3 INDIA

City/Town/Village* SIDHESWARPUR District* CUTTACK Pin Code* 754100

State* ORISSA Country* INDIA

Address Type* Residential/Business ✔ Residential Business Registered Office Unspecified

Applicant e-SIGN

1
B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)
Line 1* SUKANTA KUMAR SAHOO, 21, SIDHESWARPUR, HIGH SCHOOL

Line 2 ROAD, SIDHESWARPUR, 754100, CUTTACK, ODISHA,

Line3
INDIA
City/
SIDHESWARPUR CUTTACK 754100
Town/Village* District* Pin Code*
ORISSA INDIA
State* Country*
Address Type* Residential/Business ✔ Residential Business Registered Office Unspecified
Proof of Address* (attested copy of any 1 POA for correspondence and permanent address each to be submitted)
✔ A — Aadhaar Card 0244
XXXX XXXX __ __ __ __
B — Passport Number (Expiry Date)

C — Voter ID Card
(Expiry Date)
D —Driving License
E —NREGA Job Card
F — NPR Letter
Z—Others (any document notified by Central Government)

Identification Number

3. Contact Details (in CAPITAL)


Email ID* rashmikantsahoo123@gmail.com
________________________________________________________________________________________
Mobile No. * _____
91 9778737618
____________________________
Tel (Off) _____ ____________________________ Tel (Res) _____ ____________________________

4. Applicant Declaration
I/We hereby declare that the KYC details furnished by me are true and correct to Applicant e-SIGN Applicant Wet Signature
the best of my/our knowledge and belief and I/we under-take to inform you of any
changes therein, immediately. In case any of 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 for it.
I/We hereby consent to receiving information from CVL KRA through SMS/Email on
the above registered number/Email address.
I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be
validated against Aadhaar details. I/We hereby consent to sharing my/our masked
Aadhaar card with readable QR code or my Aadhaar XML/Digilocker XML file, along
with passcode and as applicable, with KRA and other Intermediaries with whom I
have a business relationship for KYC purposes only.
27/11/2024
DATE: _________________________ (DD-MM-YYYY)
GURGAON
PLACE: _______________________________________

5. For Office Use Only


In-Person Verification (IPV) carried out by* Intermediary Details*

IPV Date 27/11/2024 Self certified document copies received (OVD)

Emp. Name SUDHA VERMA


✔ True Copies of documents received (Attested)
AMC / Intermediary Name :
Emp. Code 15170093
BANAYANTREE SERV LTD
Emp. Designation VERIFYING OFFICER

Employee Signature and Stamp Institution Name and Stamp

2
Proof of Identity / PAN (mandatory)

5
Proof of Address (mandatory)

6
Applicant Wet Signature Page (mandatory)

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