CHECK LIST FOR AUTHORISED PERSON REGISTRATION (NSE & BSE) FOR CASH,

DERIVATIVE AND CURRENCY FOR INDIVIDUAL / SOLE PROPRIETOR

FAN Code : FAN Name :SHIV KUMAR Location Zone
CHANDAK BIKANER
Tel No: RM Name :ASHISH AGARWAL Date of Receipt

Sr. Checklist BSE NSE

No
MANDATORY DOCUMENTS AS PER EXCHANGE
1 Cheque for Authorised Person Registration Fees in favor of “India Rs.2280 Rs.6840
Infoline Ltd” payable at Mumbai (Non refundable).
For an amount calculated @ Rs 2290- for each segment of every
exchange as below: ( 1 cheque required for all segments instead of
separate cheques)
It must be deposited under AXIS Bank INDIA INFOLINE LTD
A/c no. 062010200005203
2 Agreements each On Non judicial Stamp Paper Of Rs 100/-
Signed and stamped of Individual / Proprietor on each page
a) Trading Member and Authorised Person Agreement-BSE 
b) Trading Member and Authorised Person Agreement -NSE 
c) Alliance Partner agreement 
d) IIFL-Empanelment-Form.pdf 
3 Following documents need to be self attested and In person verification by
B.D.M. on each Proofs
(a) Copy of PAN card (Age not less than 18 years )  
(b) Copy of education proof (Min. Education - 10th pass)  
Mark sheet or Passing certificate of examination passed
only)
(c) Proof of Office Address (on trade name in case of  
proprietor)
– One of the following
 Landline Telephone Bill*
 Electricity bill*
 Bank pass book*
 Voters id
 Driving License#
 Passport #
 Bank Statement*
 Shop Establishment Certificate
 Ration Card
 Rent Agreement with Residence Address proof
* Only the latest ( not more than 3 months old )
 # Valid for next 3 months
 (d) Proof of Residence Address – (Authorized Person should  
be citizen of India)
 Landline Telephone Bill*
 Electricity bill*
 Bank pass book*
 Voters id card
 Driving License #
 Passport #
 Bank Statement*
 Ration card
*Only the latest ( not more than 3 months old )
 # Valid for next 3 months
4.
(a) BSE (Annexure 2b(i) 
(b) BSE (Annexure 2b(ii) 
(b) NSE (Annexure 2) 
5. Application Form for BSE (Should be completely filled in and 
details should match with the proofs provided)
NON - MANDATORY DOCUMENTS , REQURIE AS PER NEED

1. In case of married women -  

Marriage affidavit on stamp paper duly notarized. And it should

be on Non judicial Stamp Paper.

2. 1. Change in name on account of marriage √ √

• Marriage Certificate or
• Copy of Passport showing husband’s name or
• Publication of name change in official gazette.

2. Change in name on account of reasons other than marriage

• Publication of name change in official gazette.

3. Change in father’s name

• Publication of name change in official gazette.

3. A) In case of minor mismatch in name, affidavit of name change  

duly attested by notary (name mismatch in PAN card with other
proof given) Non judicial Stamp Paper or Gazette Notification in
case of major differences.

B) In case of minor mismatch in father/ relative‘s name, affidavit

of name change duly attested by notary (name mismatch in PAN
card with other proof given) Non judicial Stamp Paper. or Gazette
Notification in case of major differences.
 INTERNAL DOCUMENTS

1. Online FAN payout form (For detailed please refer circular dated 
February 09, 2009, ref no. 2009/02/019, subject: Compulsory
online FAN payout for FAN-P). Required documents –
1)Cancelled cheque
2) Latest Bank statement [not more than 3 months old]
(Required only if name on cancelled cheque is not pre-printed)

2. Undertaking of Not to deal with Trading Member (TM) other than 

TM/Broker where registered
3. FAN Application Request letter on FAN letterhead 

4. Covering letter

5 Registration Fees 

6 Deposit 

7. Undertaking  
(1.) Individual
(2.) Proprietor

For Relationship Manager at local branch only

I …ASHISH AGARWAL.. (Name) C133892 (Employee Code) hereby confirm that I have
checked the complete set of registration documents and all documents required per the
checklist is attached. I know the applicant for last… months/years personally and am
financially sound and having moral character and integrity

Name and Signature

 APPLICATION FORM BY THE APPLICANT FOR REGISTRATION AS AUTHORISED
PERSON WITH TRADING MEMBER OF BSE LTD.
(As per Rules, Bye Laws & Regulation of the Exchange)

1 Name of applicant SHIV KUMAR CHANDAK

(applying for registration of Authorised Person.)

2 Trade name : SHIV KUMAR CHANDAK

(of Authorised Person/ Partnership firm/
Corporate body)

3 Segment BOTH
1. Cash Segment 2. Derivatives Segment 3.
Both

3 Type of organization Type of organization: INDIVIDUAL

(sole proprietor/partnership/LLP/corporate body)
[Kindly provide name/s of proprietor Names of Partners/Directors:
/partners/directors] 1_______________________________
2_______________________________
4 Office address (with proof) RAMDEV MANDIR WALI GALI,
(place from where authorised person will be DAMMANI CHOWK, BIKANER,
operating - covering area, street/road, city/dist., BIKANER - 334001
state & PIN etc., all fields are compulsory).

5 Contact Person Name, SHIV KUMAR CHANDAK

Office Telephone,
Mobile Numbers, 9351204235
Fax Numbers , Email ID sc_chandak@yahoo.co.in
6 Residence address (with proof) with telephone RAMDEV MANDIR WALI GALI,
number DAMMANI CHOWK, BIKANER,
(i.e. of proprietor/all partners/all directors - BIKANER - 334001
covering area, street/road, city/dist., state & PIN
etc., all fields are compulsory).

7 Education qualification & Date of Birth (with B.Com

proof) 18/06/1956

(of proprietor / all partners / all directors with

proof are compulsory)

8 PAN Number of the applicant & applicant firm ABAPC0152E

and of proprietor/all partners/all directors with

proof is compulsory.

9 Name and clearing no. of main Trading Member

to whom applicant is affiliated
10 Date of signing agreement with the Trading
Member

11 Authorised person affiliated to a Trading Member

in any other stock exchange - if Yes,
provide details of Registration No. & Date with
 details of name of member to whom he/she/they
is/are affiliated.

12 Whether any case/claim/arbitration pending

against the authorised person in any court/stock
exchanges (provide details)

13 In case applicant is member of a

Regional/Multiple Stock Exchange, details of
SEBI Registration No. & Date of Registration

I certify that the information given in this application form is true to the best of my/our
knowledge and belief.

Date : Signature of applicant

Place: (With stamp)

 UNDERTAKING

SHIV KUMAR CHANDAK

RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

[An applicant should submit this confirmation/declaration/undertaking while

submitting an application for Authorized Person registration]

Dy. General Manager

Membership Compliance Dept.
Bombay Stock Exchange Ltd.
Mumbai

I/We hereby confirm/declare/undertake that (Name of proprietor/all partners/all directors

as applicable should be mentioned) have not been convicted of any offence involving
fraud or dishonesty and no trial is pending against above applicant/s in any court of law.

I/We hereby confirm/declare/undertake that the SEBI has not taken any action like
cancellation of registration / or debarred or prohibited any of the applicant /s from
dealing in securities market/imposed penalty after adjudication/prosecution etc. against
any of the applicant/s (names as applicable)

In case of non-compliance on any of above or in case this

confirmation/declaration/undertaking is found to be false, the Exchange may take
necessary Disciplinary action as per the Rules, Byelaws and Regulations of BSE
Limited

Signature of Applicant

Individual / Proprietor
(with rubber stamp)

Date:
 Annexure - 2

Undertaking

SHIV KUMAR CHANDAK

RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

I Mr./Ms. SHIV KUMAR CHANDAK (name of the applicant authorised person) had applied
for appointment as Authorised Person of the Stock Exchange on

(Tick the segment (s) applied for)

 Capital Market

 Futures & Options

 Currency Derivatives

segment (s) through trading member, M/s.India Infoline Limited, In this regard, I hereby
confirm/undertake that:

1. I have not been convicted for any offence in the past and presently and not under trial for
any offence involving fraud and dishonesty.
2. I will deal with investors on behalf of Trading Member only and that I would not engage in
any activities with investors which could result in unauthorised intermediations.
3. I am neither an Authorised Person of any other member of the stock exchange and nor
has/have applied for appointment as Authorised Person with any other member of the stock
exchange.
4. I confirm that I am not a defaulter/expelled on any stock exchange.
5. I confirm that I am “fit and proper” under SEBI (Intermediaries) Regulations, 2008 and no
action has been taken against me by SEBI, RBI, etc. and I have not defaulted in payment to
any agency.

Date: ______________

Place: ______________ _________________________________

_________________________________
* Name, Signature & Seal
 Undertaking
SHIV KUMAR CHANDAK
RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

I/We, Mr./Ms./M/s SHIV KUMAR CHANDAK (name of the applicant/ authorised person)
had applied for appointment as Authorised Person of the National Stock Exchange of India
Limited (“NSE”) Bombay Stock Exchange (“BSE”) , (NSE and BSE collectively referred to as
“Exchanges”) on Capital Market / Futures & Options / Currency Derivatives Segment(s)
through India Infoline Limited (“the Trading Member”). In this regard, I/We hereby
confirm/undertake that:

1. I/We, partners / directors is/are/am fit and proper person(s) to be registered as an

Authorized Person.
2. I/We, partners / directors have good financial background & reputation, moral character
and integrity and have not been convicted of any offence involving fraud or dishonesty.
3. I/We am/are neither a Trading Member or Sub broker/Authorised Person of the
Exchanges nor a Proprietor/Partner/Director of any other Trading Member or Sub
broker/Authorised Person of the Exchanges
4. I/We also undertake that, we shall obtain prior permission of the Trading Member /
Exchange for any changes like change in trade name/name, address and status and
constitution and I/We shall meet the eligibility criteria of being appointed a Authorised
Person at all times.
5. I/We shall maintain necessary infrastructure like adequate office space, equipment and
manpower to effectively discharge the activities as may be directed by the Trading
Member;
6. The funds and securities of the clients shall be settled directly between the Trading
Member and client. I/We shall provide all the administrative assistance in procurement
of documents and settlement, but shall not issue any document to client in my/our own
name. No fund/securities of clients shall go to my/our account;
7. I/we shall not receive or pay any money or securities in my/our own name or account
and all receipts/payments of securities and funds shall be in the name or account of the
Trading Member,
8. I/We shall not charge any amount as brokerage from the clients
9. I/We shall, at all times, comply with all the conditions laid down for Authorized Person.
10. I/We shall comply with the Rules, Byelaws, Regulations, directions and circulars issued
by Securities & Exchange Board of India, Exchanges and Trading Member from time
to time;
11. I/We, partners/ directors shall hold the valid NCFM/NISM/BSE certification at all times
and ensure to renew the same from time to time;
12. I/We shall display at each office additional information such as particulars of authorised
person in charge of that branch, time lines for dealing through authorised person, etc.,
as may be specified by India Infoline Limited/ Exchanges/SEBI;
13. My/Our name and / or names of the partners / directors is not appearing in SEBI
debarred persons, Directors/ Vanishing Companies List;
 14. My/Our name and / or names of the partners / directors is not appearing in CIS and Non
CIS list or CIBIL database;
15. I/We have not, at any time introduced or otherwise dealt with fake, forged, stolen,
counterfeit, etc. shares and securities in the market,
16. Before seeking a withdrawal as an Authorised Person I/We shall give a notice of
minimum forty-five days to the Trading Member.
17. I/We shall provide all co-operation for any periodic inspection conducted by the
Trading Member /Exchanges/SEBI of offices and records of the operations carried out
by me/us;
18. I/We understand that the Trading Member may seek withdrawal of my/our registration
as Authorised Person on noticing any irregularities in my/our operations and shall
withhold all moneys due to me/us till resolution of investor problems, shall file a
complaint with the police, and shall take all such measures required to protect the
interest of investors and market as the Trading Member may think fit;
19. I/We shall be responsible for all deals, acts of commission and omission, quotations
made and transactions effected, if any, by / through me/us and/or our employees,
including liabilities arising there from and I/We hereby undertake to indemnify and
keep indemnified the Trading Member, its Directors and employees at all times in this
regard;
20. I/We hereby confirm that the information that has been submitted by me /us is true to
the best of my/our knowledge and if at a later date if any material information comes to
my/ our knowledge subsequent to the date of this undertaking, I/We undertake to keep
the Trading Member informed about the same.

Date: ______________
Place: ______________ _________________________________
*Name, Signature & Seal

*Should be signed by Individual / Proprietor of the Authorised Person.

On the letterhead of IIFL

For Short Address Undertaking In BSE

Member Confirmation for AP Address Proof

To,
Membership Compliance,
Bombay Stock Exchange Ltd.

Date:

Dear Sir,

Trade Name of Authorised Person : SHIV KUMAR CHANDAK , having address- RAMDEV
MANDIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001,

We herby confirm that our representative has personally verified aforesaid address and it is complete in
all respect. We are also attaching AADHAR CARD as an address proof as per Exchange requirement.

I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.

Yours faithfully

For INDIA INFOLINE LTD

Authorised Signatory
 SHIV KUMAR CHANDAK
RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

For Short Address Undertaking In NSE

Member Confirmation for AP Address Proof

To,
Membership Compliance,
National Stock Exchange Ltd.

Date:

Dear Sir,

Trade Name of Authorised Person : -SHIV KUMAR CHANDAK , having address- RAMDEV
MANDIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001, .We
herby confirm that our representative has personally verified aforesaid address and it is complete in all
respect. We are also attaching _AADHAR CARD as an address proof as per Exchange requirement.

I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.

Yours faithfully

Signature of Applicant
Proprietor / Partner / Director
(with rubber stamp)

Date:
 Bank Sign Verification letter for BSE and NSE

Date :

From :-

To,

Subject : Request to verify my signature

Respected sir,

As I am maintaining my saving account to ______________. My saving account No

___________________________ Now I need verification for my signature to submit documents
to India Infoline ltd for Authorised Person Registration
You are requested to verify the same.

Specimen Signature as per pan card __________________

Specimen Signature as per bank account ___________________

Specimen Signature as per Authorised Person Registration documents ___________________

Thanking you,

Yours Faithfully,

SHIV KUMAR CHANDAK

RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in
To,
India Infoline Ltd.
3rd Floor, IIFL House, Sun Infotech Park,
Road No. 16V, Plot No. B-23,
MIDC, Thane Industrial Area, Wagle Estate,
Thane - 400604.

Sub: Request for ONLINE TRANSFER of payout.

Dear Sir,
With reference to the above subject, you are requested to transfer my monthly payout to below
mentioned bank account
FAN Code
FAN Name
Fan Address

Pin code: State:

Bank Details:
Beneficiary Name
(Name of A\C
Holder)
Bank Name
Bank Account
Number
Bank Account Type o Savings o Current
Bank Branch Address

Pin code: State:

MICR Code *
IFSC Code **
* 9 Digit Code number of the Bank & branch appearing on the cheque issued by the bank
** This code is printed on the cheque and if the same is not printed on the cheque it should be
obtained from the respective bank of the account holder. Also if the FAN is having an ‘at par’
account with any bank, the IFSC code mentioned on the cheque would be the common IFSC
code of the Bank; in such cases the IFSC code of the respective local Branch needs to be
obtained from the Bank.
ENCL: 1) Cancelled cheque leaf
2) Latest account statement.

Thanking You,
Authorized Signatories

SHIV KUMAR CHANDAK

RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
 MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

Date :

From
……………………………….
………………………………
………………………………
…………………………………

To
M/S India Infoline Ltd
Mumbai.

Ref: Fancode - ………………

Subject: Franchisee Deposit of ……………………………………………………

1 I/ We am /are enclosing / deposited herewith chq / DD No………………………..

Dated. ………………… For the amount Rs …………………………………….
(Words: ………………………................................................................................)
drawn on bank …………………………………………………… ... In favour of
India Infoline Ltd A/c No………………………Of..……………………….Bank

Please Acknowledge

Place Name Sign

 SHIV KUMAR CHANDAK
RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

Undertaking

Subject: Not to deal with Trading Member (TM) other than TM/Broker where registered

I / We _____SHIV KUMAR CHANDAK__an individual/ company/ firm having residence

address/ registered office at RAMDEV MANDIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN -
334001 I/we hereby undertake that I/we are not dealing any proprietary trading or for trading on
behalf of clients other than India Infoline Ltd where I/we are registered.
If at any time it found violation of above provision then then SEBI/Exchange can initiate
necessary disciplinary action against me / us as per provision.

Sub-broker name: Date:

Place:
Signature:
(Stamp in case of Proprietor)
 SHIV KUMAR CHANDAK
RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in

___________________________________________________________________________

I, ______________________________ , son of ___________________________ aged __,

resident of __________________________________________________________________,
Hereby declare that there was /is no adverse action whatsoever, such as enquiry/adjudication
(penalty imposed) / Suspension / Cancellation / Prosecution / de-barring from capital market,
initiated / pending / completed against me ______________________________, by SEBI or
any other authority / institution, either in past or at present.

Further, I, ______________________________ also confirm that, I am/was not ever

associated / connected, in any capacity whatsoever, with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

I further confirm that ______________________________ is/ was not ever associated with
_____________________________________________________________
_________________________________________________________________
_________________________________________________________________

I further confirm that ______________________________ is / was never associated with

any stock exchange.

I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.

Place:

Date: (Signature)

Pan No:

SHIV KUMAR CHANDAK

RAMDEV MADIR WALI GALI, DAMMANI CHOWK, BIKANER, RAJASTHAN - 334001
MOBILE: 9351204235 | EMAIL: sc_chandak@yahoo.co.in
I, ______________________________ Son of ______________________________ aged
__,years resident of
_________________________________________________________________ , is
Proprietor of ______________________________ Hereby declare that there was /is no
adverse action whatsoever, such as enquiry/adjudication (penalty
imposed)/Suspension/Cancellation/Prosecution/ de-barring from capital market, initiated /
pending / completed against me ______________________________ or against my firm
______________________________ by SEBI or any other authority / institution, either in
past or at present.

Further, I, ______________________________ also confirm that, I am/was not ever

associated / connected, in any capacity whatsoever, with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

I further confirm that ______________________________ is/ was not ever associated with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

I further confirm that ______________________________ Proprietor of

______________________________ is / was never associated with any stock exchange.

I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.
_________________________
(Signature & Stamp)
Place:
Date: (Signature)
Pan No :