Know Your Client (KYC)

Application Form (For Individuals Only)

Please fill the form in ENGLISH and in BLOCK letters

Fields marked * are mandatory Application Number: 21312161603629

+
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* Please enclose a duly attested copy of your PAN Card
____________________________
MGOPK3913N

Name* (same as ID proof) AKHILESH KUMAR

Maiden Name+ (if any)

Fathers/Spouse’s Name* MATADEEN KUMAR
Date of Birth* 28/06/2004
Gender* Male Female Transgender
Marital Status* Single Married
Nationality* Indian Other
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* S/O Matadeen D-98 Sector -Swarn Nagri Greater
Line 2 Noida Kasana Uttar Pradesh Uttar Pradesh
Line3 Uttar Pradesh
City/Town/Village* Kasana District+ Gautam Buddha Nagar Pin Code* 201310
State* Uttar Pradesh Country* India
Address Type* Residential/Business Residential Business Registered Office Unspecified

Applicant e-SIGN

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B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)
Line 1* S/O Matadeen D-98 Sector -Swarn Nagri Greater
Line 2
Noida Kasana Uttar Pradesh Uttar Pradesh
Line3
Uttar Pradesh
City/
Town/Village* Kasana +
District Gautam Buddha Nagar Pin Code* 201310
State* Uttar Pradesh Country* India
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 XXXX XXXX __ __ __ __
9284
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*
________________________________________________________________________________________
AKHILESHKUSHWAHA9599@GMAIL.COM
Mobile No. * _____ ____________________________
9599630450
Tel (Off) _____ ____________________________ Tel (Res) _____ ____________________________

4. Applicant Declaration

I hereby declare that the details furnished above are true and correct to the best of
Applicant e-SIGN Applicant Wet Signature
my knowledge and belief and I undertake 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 aware that I may be held liable for it.
I/We hereby consent to receiving information from KRA / Central KYC Registry
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.
I/We hereby give my/our consent to Kotak Securities Limited (KSL) to access and/or
download my/our CKYC record from the Central KYC Records Registry (CKYCRR) for
the purpose of account opening or for carrying out any modification of details in my/
our account. I/We also agree and confirm to share any and all such records with all
Regulators including but not limited to KRAs (Know Your Client Registration Agency)
for the purpose of validation of KYC by the KRAs, and shall also be stored by KSL for
record purpose.

22/09/2024
DATE: _________________________ (DD-MM-YYYY)
Kasana
PLACE: _______________________________________

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 5. For Office Use Only

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

IPV Date Self certified document copies received (OVD)

Emp. Name True Copies of documents received (Attested)

AMC / Intermediary Name :
Emp. Code

Emp. Designation Kotak Securities Ltd.

Kotak Securities Ltd.

Employee Signature and Stamp Institution Name and Stamp

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 DIGILOCKER Verified E- Aadhaar

This is the document generated by Kotak Securities with resident’s (client 's) express consent and on the basis of
E-Aadhaar generated from Digilocker verified Aadhaar XML shared by the resident (client ) with Kotak
Securities for the purpose of opening Trading and/-or Demat account . This document will be used as an ID and /-
or Address proof for record purposes.

Document Type E-Aadhaar generated from Digilocker verified Aadhaar XML

Generated Date 2024-09-22 10:17:17 AM Downloaded Date 2024-09-22 10:08:42 AM
Masked Aadhaar xxxxxxxx9284
Name Akhilesh Kumar
Date of Birth 28-06-2004
Gender MALE
C/o , S/o

S/O Matadeen D-98 Sector -Swarn

Nagri Greater Noida Kasana Uttar
Address Pradesh Uttar Pradesh, ,, Gautam
Buddha Nagar, Uttar Pradesh, 201310,
INDIA

Landmark Locality

City / District Gautam Buddha Nagar

Pin code 201310 State Uttar Pradesh