Resident Individual Account Opening Form for Trading and Demat Account

3-IN-1 ACCOUNT OPENING FORM

Application Form No. : 5208939364

1. The Account Opening from has been divided into 3 parts - PART A, PART B and PART C
2. PART A of the form captures your Demographic and other details necessary for opening your account(s). After satisfactory
processing of PART A, our representative would approach you once again with PART B.

FORM TYPE E INVEST PREFERRED CONTACT TIME:

ERS ONLINE
Between am / pm
CHANNEL PARTNER
(Sub Broker, AP, IA/IFA)
OR am / pm
INDIVIDUAL
8505741729
AGENT/BROKER CODE: KYC CAT CODE :

BANK/TL/SM/SUB AGENT CODE : ANNEXURE FORM :

OTHER CODE : PPA CODE :

HH (Bank Team) BB CODE (Bank Branch Code)

LEAD NUMBER : CHANNEL :

(Channel sales/Center sales/RCLG sales/IBG/Others)

IMPORTANT INSTRUCTIONS
1. Please do not give any blank cheques or cash to the sales executive.
2. Please ensure that you are aware of all the terms and conditions applicable to your bank account and demat account.
3. If the cheque for account opening fees is returned on account of any reason, ICICI Securities Limited would recover the same by
debiting your linked ICICI Bank account at later date.
4. If the cheque for account opening fees is returned on account of any reason, ICICI Securities Limited would recover the same by
debiting your designate ICICI Bank account at later date.
5. You can view standard account opening documents on www.icicidirect.com> customer service > useful links > Client
Registration Documents in Vernacular Language.
I have read and taken note of the above important instructions.

ICICI Securities Ltd. Version 627

 Account Opening Form (For Individuals Only) Know your Client (KYC) KYC Mode.: KRA Verified DigiLocker
Aadhar XML

Application No.: 5208939364

Please fill in ENGLISH and in BLOCK LETTERS
 A. Identity Details (please see guidelines overleaf)
1. Name of Applicant (As appearing in supporting identification document).
Name LIPINA BEHERA
PHOTOGRAPH
Maiden Name (If any)
Father’s Name MANGULI BEHERA Please affix
Spouse Name the recent passport
size photograph and
Mother’s Name
sign across it
2. Gender Male Female Transgender B. Marital status Single Married Others
C. Date of Birth 14-APR-1994 3. Nationality Indian Other
4. Status Please tick (3 ) Resident Individual Non Resident Foreign National (Passport Copy Mandatory for NRIs & Foreign Nationals)
Person of Indian Origin
*5. PAN GQFPB2552B Please enclose a duly attested copy of your PAN Card
6. GST No. (Pls provide GST registration certificate)

 B. Address Details (please see guidelines overleaf)

1. Address for Correspondence
BASELIHATA ,BALIJHARI ,BALIJHARI ,CUTTACK ,ODISHA

City / Town / Village CUTTACK District CUTTACK Pin Code 754037

State ODISHA Country INDIA
2. Contact Details
Tel. (Off.) (ISD) (STD) Tel. (Res.) (ISD) (STD)
Mobile (ISD) (STD) 9937201340 Fax (ISD) (STD)
Email ID [email protected]
I here by declare that the mobile number mentioned above belongs to: Self Spouse Dependent Parent Dependent Children
I here by declare that the Email ID mentioned above belongs to: Self Spouse Dependent Parent Dependent Children
3. Proof of address to be provided by applicant. Please submit ANY ONE of the following valid documents & tick (3 ) against the document attached
Passport UID (Aadhaar) Narega Job Card Driving License *Latest Gas Bill *Voter Identity Card *Latest Electricity Bill
*Latest Bank A/c Statement/Passbook *Latest Telephone Bill (only Land Line) Others (please specify)
* Not more thant 2 Months old. Validity/Expiry date of proof of address submitted
4. Permanent Address of Resident Applicant if different from above B1
BASELIHATA ,BALIJHARI ,BALIJHARI ,CUTTACK ,ODISHA

City / Town / Village CUTTACK District CUTTACK Pin Code 754037

State ODISHA Country INDIA
Permanent Address Type Residential / Business Residential Business Registered Office Unspecified
5. Proof of address to be provided by Applicant. Please submit ANY ONE of the following valid documents & tick (3 ) against the document attached.
Passport UID (Aadhaar) Narega Job Card Driving License *Latest Gas Bill *Voter Identity Card *Latest Electricity Bill
*Latest Bank A/c Statement/Passbook *Latest Telephone Bill (only Land Line) Others (please specify)
* Not more thant 2 Months old. Validity/Expiry date of proof of address submitted
 DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my/our 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 misleading or misrepresenting, I am/we are aware that I/we may be held liable for it.
Place CUTTACK Date 16-10-2022
SIGNATURE OF THE APPLICANT

Note:For the purpose of online account opening, KYC verification means checking of customers Live photo and verification of KYC documents.

ICICI Securities Ltd.

 PART A
Account Opening Form (For Individuals Only)
Details of Sole Applicant
Gross Annual Income Details Please Tick ( 3 ):
<1 Lakhs 1-5 Lakhs 5-10 Lakhs 10 to 25 Lakhs > 25 Lakhs or Net-worth in
__________________
as on (date)

Additional Details
Primary Source of wealth
Salary Business Gift Royalty Rental Income Prize money Ancestral property Others Business
______________
Account Reference Number (ARN) :
PEP Details - Please tick applicable (For defination of PEP, Please refer Part C)
Politically Exposed Person (PEP)
Related to a Politically Exposed Person (RPEP)
I am not Politically Exposed Person neither, I am Related to a politically Exposed Person
Occupation (Please tick (3 ) any one
Private Sector Service Public Sector Government Service Professional Self Employed
Retired Housewife Student Business Not Categorised

Prime Membership Form

299 999 1999 2999 I want my Prime Plan to be Auto renewed

Education
Under Graduate Non Matric SSC HSC Graduate Post Graduate Professional Others______________
Graduate
ICICI Bank Account Details (For Existing Bank Account)
Existing Bank Account to be linked:
If you already have bank account with ICICI Bank and wish to link it with ICICIdirect.com Account, mention your account details in the space provided. The 'Sole
Applicant' of the trading account should be the first Holder in this account.The name and signature in the Bank's record must match with the signatures on the
form. I wish to link my Existing Saving Bank Account :
Existing Saving Bank A/C No: _________________________________ IFSC Code: _____________________________________
Branch: _________________________________ MICR Code: _____________________________________

Designated Bank Account Details

PART A: DECLARATION FROM CUSTOMER FOR DESIGNATED BANK A/C*(Cheque with preprinted name or Bank Passbook Statement containing Client name and
Bank a/c number. I hereby request that the following bank accounts be treated as my Designated Bank A/cs*for the purpose of Payment gateway Mechanism of
3in1 Account with ICICI Securities Ltd. (I-Sec). I hereby declare and confirm that I am the holder of these accounts, that these accounts belong to me and that the
funds used for the purpose of investment are from legitimate sources. I further understand that any payment made by me from an account other than those specified
herein below is liable to be rejected and/or my 3in1account deactivated, unless/submit the Bank A/c details and proof of holding the Bank A/c in my name within
the prescribed timelines.Further, I hereby agree and understand that my transactions may be monitored under PMLA Guidelines and/ undertake to provide such
further details as may be required by l-Sec for the same. Further confirm that whatever is stated herein is true and correct to the best of my knowledge and/ hereby
indemnify ICICI Securities Ltd. against any loss incurred due to any incorrect information provided by me.
BANK ACCOUNT DETAILS
Bank Name HDFC BANK Branch: KANJURMARG WEST
Branch City Name MUMBAI Bank A/C No: 50100565656827
A/C Type Saving Current Single Holder Joint Holder
Customer name as appears on bank A/c : LIPINA
IFSC Code: HDFC0004272 MICR Code: 400240196
Note *: 1. Designated Bank a/c can be accounts of only those banks that provide customer account number details to ICICI Securities Ltd. for verification of fund
receipt. Payments from such bank a/cs only will be acceptable towards investment limit of the client List of approved banks will be available on our website. Any
change/addition/deletion in the list will be informed to the customers. 2. I hereby authorise ICICI Securities Ltd. to verify my Bank account details given by me at
the time of account opening using Penny drop facility. 3. The bank account will be used for disbursing dividends/ interest and may also be used for recovering all
Demat charges & brokerage charges in respect of the account. Please provide correct details to avoid errors while doing the same. Further bank account appearing
at no.______ i.e. ______ (Bank Name) ________________________may be considered as my default bank account for all redemption or withdrawals as
requested by me from time to time or as initiated by I-Sec and such funds be transferred to such account. I/We understand that in case I/We have linked ICICI
Bank Account at present or anytime in future, the same only shall be considered as my default bank account for all such purpose.
 I wish to link my existing Resident Individual NSDL Demat account with

✘
No
ICICI Securities Ltd.
 C. DECLARATION
1. I hereby declare that the details furnished in the account opening form are true and correct to the best of 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/we are aware that I may be held liable for it. 2. I confirm having read/been explained and
understood the contents of the document on policy and procedures of the stock broker and the tariff sheet. 3. I understand that ICICI
Securities Ltd. has uploaded in my ICICIdirect.com account, Part C of the Account Opening Form containing Rights and Obligations of
Stock Broker, Sub broker and Client for trading on Exchanges, Rights and Obligation of Stock broker and Clients for Trading in Margin
Trading Facility (MTF), Rights and Obligations of Beneficial owner and Depository participants, Uniform Risk Disclosure document,
Guidance Note detailing Do's and Dont's for trading on Exchanges, Policies and Procedures, Letter of Confirmation and schedule of
charges. I have downloaded, read and understood the contents and accept conditions specified in the above mentioned documents. I
have also been informed that the standard set of documents has been displayed on www.icicidirect.com. 4. The rules and regulation of
the Depository Participants pertaining to an account which are in force now have been read by me/us and I have understood the same
and I agree to abide by and to be bound by the rules as are in force from time to time for such accounts. I/we acknowledge the receipt
of copy of the document, “Rights and Obligations of the Beneficial Owner and Depository Participant”. 5. Under penalty of perjury, I
certify that: The applicant is (i) an applicant taxable as a US person under the laws of the United States of America (”U.S.”) or any
state or political subdivision thereof or therein, including the District of Columbia or any other states of the U.S., ii) an estate the
income of which is subject to U.S. ( federal income tax regardless of the source thereof. (This clause is applicable only if the account
holder is identified as a US person) or 6. The applicant is taxable as a tax resident under the laws of country outside India. (This clause
is applicable only if the account holder is a tax resident outside of India) 7. In case of any change in my Tax residency status on a
future date, I undertake to inform I–Sec within 30days. I agree that if I am a US Person or tax resident of any other foreign jurisdiction
requiring reporting under FATCA/CRS or any other laws, my account details as required under these laws, would be reported by I-Sec
to the relevant tax authority. 8. If my Country of Birth is Other than India and US and I do not have TIN or FE, then I / We hereby
confirm that I/ We am/are not a Tax resident for tax purpose in any country other than India and US. 9. I hereby consent to receive
information from Central KYC Registry through SMS/Email on the registered number/email address as mentioned in KYC form. I hereby
confirm that details as provided by me above can be shared by I-Sec with the concerned Asset Management Companies (AMCs),
Insurers or such other product providers, to whom CKYCR norms are applicable, in whose schemes/ products I may invest/transact in
future through I-Sec or as required by any regulator or under any law. 10. I hereby authorise ICICI Securities Limited / ICICI Bank Ltd to
fetch and download my details from Central KYC Registry. I also hereby authorise ICICI Securities Ltd / ICICI Bank to modify and update
my existing details in Central KYC Registry with my latest KYC details provided in this account opening form. I / We declare that not
providing details of mobile no and or email id in the account opening form shall be considered that I / We do not have same to provide.
11. I/We request ICICI Bank to issue Banker Verification Letter for my ICICI Bank account mentioned in the account opening form for
the purpose opening trading account with ICICI Securities Ltd. 12. I hereby authorise ICICI Bank Ltd. to share/ communicate any
change in my bank account status, Immediately to ICICI Securities Ltd. 13. I hereby authorize ICICI Securities Ltd. to collect from ICICI
Bank Ltd my demographic details like name, PAN, Address, Date of Birth, Email id, Mobile number and such other details as may be
required by ICICI Securities Ltd for opening my trading account. ICICI Bank will also be using the details to open a demat account. 14. I
hereby authorize ICICI Securities Limited to access/ share my e-addhaar through DIGILOCKER or shared/ uploaded by me for the
purpose of opening account with ICICI Securities Limited. ICICI Securities Limited shall maintain the aadhaar details confidential and
shall not disclose the same to any person except as required under any rules, regulations, circulars etc. or its amendment thereof
issued by regulators from time to time or to KYC Registration Agencies (KRA), CERSAI or to group companies in this regard or part of
KYC documents. 15. I/We hereby authorize ICICI Securities Ltd to carry out all/any transactions on our/my behalf from the date of
opening of the account as may be specified in the Power of Attorney. 16. I / We have reviewed, verified and confirm the KYC and other
details filled in app during account opening. 17. I / We Understand that in case this account opening form is not received by ICICI
Securities Limited (I-Sec) within 10 working days of account opening, I-Sec reserves the right to temporarily suspend my account and
close / square off / liquidate / redeem positions taken or investments in products done by me. 18. I confirm that I have consented for
opening of demat and trading account electronically through computer /tablet/mobile phone/ any electronic device. I confirm that the
information and instruction which are provided by me and captured electronically are read by me, such information/ instructions are an
intrinsic part of my request to open a depository account and I agree to be bound by them. 19. I-SEC shall debit Demat charges or
AMC or any other regulatory / statutory charges as applicable from time to time from funds available in my ledger account if running
account authorization has been opted or from registered non-ICICI Bank Account by executing NACH mandate for the amount of
charges or AMC registered with non-ICICI Bank Account. 20. In case of any updation of non ICICI Bank account or ICICI Bank account
as ‘Default’ account with ISEC, such bank details will be passed on and updated in linked demat records of ICICI Bank Ltd for charges
and corporate actions. 21. I hereby authorise ICICI Securities Limited to accept all the orders relating to investment and/or transaction
in securities and/or other products placed by me and forward the same to the Exchange / Principals / AMCs / RTAs etc. for execution
and to submit my account opening form along with KYC documents to the Exchange / Depositories / AMCs / RTA / Principals /
Regulator bodies etc. as and when required.” 22.I understand that the accounts will be operated under the eDIS model offered by NSDL
till such time the executed Power of Attorney ('POA') is taken on record and updated against my account. Further, I hereby agree and
accord my consent that subsequent to getting redirected to the website of NSDL from ICICIdirect.com, entering the OTP and successful
validation by NSDL under the eDIS model, ICICI Securities Ltd shall be authorized to debit the eligible securities from my linked demat
account. 23. I authorise ICICI Securities ltd. to correct/update my Date of birth as updated in PAN card image or Aadhaar data
submitted by me. 24. I/We have been provided various options by ICICI Securities Ltd for establishing my / our identity / address proof
for opening the trading account and have voluntarily submitted my Aadhaar to ICICI Securities Ltd and hereby give my/our consent to
ICICI Securities Ltd:- (i) to establish my/our identity / address proof by Aadhaar based authentication system or verify the genuineness
of the Aadhaar through Quick Response (QR) code or through such other manner as set out by UIDAI or any other law from time to
time; (ii) share my/our Aadhaar detail with UIDAI, NPCI, concerned regulatory or statutory authorities as may be required under
applicable laws; I/We further authorize ICICI Securities Ltd to share my/our Aadhaar based authentication/verification detail with ICICI
Bank Limited (“ICICI Bank”) as per applicable laws, for the purpose of completion of know your customer (KYC) check for opening
demat account. I/We hereby further consent to ICICI Bank to collect / obtain such KYC documents including Aadhaar details from ICICI
Securities Ltd, and store or use the same as per applicable laws for the aforesaid purpose(s). I/We have been explained and informed in
the local language understood by me about the consent and purpose(s) of collecting Aadhaar. I/We have been informed that: (a) upon
authentication, UIDAI may share with ICICI Securities Ltd information in nature of my demographic information including photograph
which ICICI Securities Ltd/ ICICI Bank may use as an identity/address proof for the purpose of account opening; (b) my/our Aadhaar
details (including my demographic information) shared by UIDAI will not be used for any purpose other than the purpose mentioned
above or as per requirements of law ; (c) my/our biometric information will not be stored by ICICI Securities Ltd/ ICICI Bank.
25. I authorise ICICI Securities Ltd. to fetch my data and KYC documents from KYC Registration Agency (KRA) records if my PAN is
KRA verified for opening Trading account with ICICI Securities Ltd and Demat account with ICICI Bank Ltd. 26. I hereby authorize ICICI
Securities Limited to fetch my signature from the records of linked ICICI Bank account for using it as a specimen signature for my
Demat & Trading account. 27. I authorise ICICI Securities Ltd to obtain Client Master List (CML) copy from Federal Bank Ltd. or HSBC Bank Ltd. for
the purpose of verifying the details of my demat account maintained with Federal Bank or HSBC Bank Ltd. respectively and which is linked with the
trading account of ICICI Securities Ltd. 28. I further declare that the signature uploaded is my latest signature and I authorise ICICI Securities ltd. to
consider/ use this signature to be updated in my Demat account getting opened with ICICI Bank Ltd. and Trading account getting opened. I further
declare that ICICI Securities ltd shall be absolved from any liability or disputes that may arise in connection with processing the form basis this
Declaration. 29. I further declare that the signature uploaded is my latest signature and I authorise ICICI Securities ltd. to share this uploaded signature
for opening Demat acct with ICICI Bank Ltd. and Trading account with ICICI Securities Ltd. 30. I further declare that the signature uploaded is my
latest signature and I authorise ICICI Securities ltd. to consider/ use this signature to be updated in my Demat account getting opened with
ICICI Bank Ltd. and Trading account getting opened. I further declare that ICICI Securities ltd shall be absolved from any liability or disputes
that may arise in connection with processing the form basis this Declaration.

I have read and understood point nos. A, B and C and hereby agree to the same.
 # Annexure for Nomination/ No nomination for Demat & Trading Account
I/We wish to make a nomination and do hereby nominate the following person(s) who shall receive all the assets held in my / our account in the events of my /
our death
Notes for NSDL DP: 1. The nomination can be made only by individuals holding beneficiary owner accounts on their own behalf singly or jointly. Non- individuals including
society, trust, body corporateand partnership firm, karta of Hindu Undivided Family, holder of power of attorney cannot nominate. If the account is held jointly, all joint holders will
sign the nomination form. 2.A minor can be nominated. In that event, the name and address of the Guardian of the minor nominee shall be provided by the beneficial owner 3. The
Nominee(s) shall not be a trust,society, body corporate, partnership firm, karta of Hindu Undivided family or a power of Attorney holder. A non-resident Indian can be a Nominee,
subject to the exchange controls in force, from time to time. 4. Nomination in respect of the beneficiary owner account stands rescinded upon closure of the beneficiary owner
account. Similarly, the nomination in respect of the securities shall stand terminated upon transfer of the securities. 5. Transfer of securities in favour of a Nominee(s) shall be
valid discharge by the depository and the Participant against the legal heir. 6. The cancellation of nomination can be made by individuals only holding beneficiary owner accounts
on their own behalf singly or jointly by the same persons who made the original nomination. Non- individuals including society, trust, body corporate and partnership firm, karta
of Hindu Undivided Family, holder of power of attorney cannot cancel the nomination. If the beneficiary owner account is held jointly, all joint holders will sign the cancellation
form. 7. On cancellation of the nomination, the nomination shall stand rescinded and the depository shall not be under any obligation to transfer the securities in favour of the
Nominee(s). 8. Nomination can be made upto three nominees in a ICICI Bank Demat account. In case of multiple nominees, the Client must specify the percentage of share for
each nominee that shall total upto hundred percent. In the event of the beneficiary owner not indicating any percentage of allocation/share for each of the nominees, the default
option shall be to settle the claims equally amongst all the nominees. 9. On request of Substitution of existing nominees by the beneficial owner, the earlier nomination shall stand
rescinded. Hence, details of nominees entioned in the from 10. at the time of substitution will be considered. Therefore please mention the complete details of all the nominees.
10. Copy of any proof of identity must be accompanied by original for verification or duly attested by any entity authorized for attesting the documents, as provided in Annexure D.
11. Savings bank account details shall only be considered if the account is maintained with the same depository participant. 12. DP ID and Client ID shall be provided where ICICI
Bank Demat details is required to be provided.
Notes for CDSL DP:
2.This nomination shall supersede any prior nomination made by me / us and also any testamentary document executed by me / us.
1. I / We have received and read the Rights and Obligations document and terms & conditions and agree to abide by and be bound by the same and by the Bye Laws as are in
force from time to time. I / We declare that the particulars given by me/us above are true and to the best of my/our knowledge as on the date of making this application. I/We
agree and undertake to intimate the DP any change(s) in the details / Particulars mentioned by me / us in this form. I/We further agree that any false / misleading information
given by me / us or suppression of any material information will render my account liable for termination and suitable action.

1 Nominee Details Nominee 1 Nominee 2 Nominee 3

Name of the Nominee(s) (Mr./Ms.)
First Name
Middle Name
Last Name
2 Share of Each Nominee Equally (If not equally, pls specify percentage)
(Any odd lot after division shall be transferred to the first nominee mentioned in the form)
3 Relationship With the Applicant* (If Any)
4 Address of Nominee(s)
(Including City, State, Pin Code and Country)

5 Mobile No.
Telephone no. of nominee (s) (with STD code)
FAX No.
6 Email ID of nominee(s)
7 Nominee Identification details [Please tick any one of following and provide details of same]
a. Photograph and Signature b. PAN
c. Saving Bank account no d. Aadhar
e. Proof of Identity f. ICICI Bank Demat Account ID
8 Date of Birth
Sr Nos. 9 – 14 should be filled only if nominee (s) is a minor.
9 Name of the Guardian of Nominee (Mr./Ms.)
First Name
Middle Name
Last Name
10 Address of Guardian of Nominee
(Including City, State, Pin Code andCountry)

11 Age of Guardian
12 Mobile No.
Telephone no. of nominee (s) (with STD code)
FAX No.
13 Email ID of Guardian
14 Relationship of Guardian with nominee
15 Guardian Identification details[Please tick any one of following and provide details of same
a. Photograph and Signature b. PAN
c. Saving Bank account no d. Aadhar
e. Proof of Identity f. ICICI Bank Demat Account ID

I do not wish to make a nomination

SEBI circular No. SEBI/HO/MIRSD/RTAMB/CIR/P/2021/601 dated July 23, 2021 on Mandatory Nomination for Eligible Trading and Demat Accounts
I / We hereby confirm that I / We do not wish to appoint any nominee(s) in my / our trading / demat account and understand the issues involved in non-appointment of nominee(s) and further
are aware that in case of death of all the account holder(s), my / our legal heirs would need to submit all the requisite documents / information for claiming of assets held in my / our trading /
demat account, which may also include documents issued by Court or other such competent authority, based on the value of assets held in the trading / demat account.
Signature of witness, along with name and address are required, if the account holder affixes
thumb impression, instead of signature.
Witness for the Nomination for Demat Account

Name : _______________________________________________________________
Address : _____________________________________________________________
Signature of 1st Applicant Signature of 2nd co-holder Signature of 3rd co-holder
Date : ________________________ Signature :
 VOLUNTARY

Form No.

This document is voluntary, however, the same is required to be executed by the customers in order to avail of hassle free trading and settlement
services.

To,
ICICI Securities Limited
Shree Sawan Knowledge Park,
Plot No. D-507, T.T.C.Ind. Area, M.I.D.C.,
Turbhe, Opp. Juinagar Railway Station,
Navi Mumbai - 400 705.

Dear Team,

Sub: Running Account Authorisation for Trading account to be opened via above application form number.

In order to facilitate ease of operations, I/we hereby opt for Running Account Authorisation (RAA) for my/our trading account wherein funds in my/our
trading account will be settled by ICICI Securities Limited as per the frequency given below: -

Once in a Quarter Once in a Month

I/we understand that no interest would be payable by ICICI Securities Limited on funds retained in my/our trading account.

The actual settlement of funds will be done as per the preference opted by me/us stated above. I/we authorise ICICI Securities Limited to settle my/our
trading account after retaining funds as may be permitted by SEBI/ Exchanges from time to time while settling my/our account. I/we hereby authorize
ICICI Securities Limited to email me/us Statement of Account, Retention Statement and such other statements as on the date of settlement to my/our
email address registered in your records. I/we understand that for the purpose of settlement of funds, the mode of transfer of funds shall be only by way
of electronic transfer viz NEFT, RTGS etc. and the same would be credited to my/our linked bank account opened with ICICI Bank for this purpose or such
other bank account as linked to my/our trading account from time to time. I/we hereby undertake that I/we shall be keeping my/our linked bank
account(s) as Active which is/are mapped to my/our trading account. I/we hereby further undertake to provide new bank account details along with
proof(s) to ICICI Securities Limited in case of my/our existing bank account(s) is/are become inoperative for any reason and ICICI Securities Limited may
deactivate my/our trading account for further trading till bank account details are updated to my/our trading account.

This authorization shall be effective from the date notified to ICICI Securities Limited.

This authorization for maintaining my/our account on running basis can be revoked any time after giving a notice in writing to ICICI Securities Limited.

Thanking you,

Yours faithfully,

Date:________________

Client’s Signature
 Annexure
Bank Mandate and eDIS Mandate
(This document is voluntary. However, the same is required to be executed by the customers in order to avail of seamless trading platform with integrated
bank account, demat account and broking account. If you do not wish to use the services of ICICI Bank Limited and ICICI Securities Limited, you need not
execute such documents.)

To,
ICICI Bank Ltd.
Sub: Request to add a mandate holder

Reference: Addition of mandate holder in respect of existing ICICI bank account number _______________________________________________

Dear Sir / Madam,

I am desirous of appointing ICICI Securities Limited ("ICICI Securities”) as a mandate holder in respect of Bank Account with ICICI Bank Limited
("ICICI Bank”), the details of which are as follows:

Name of the Sole Holder/First Holder :

Bank Account Number :

I/We wish to participate in the trading, investment and other services and products offered by ICICI Securities. In order to facilitate proper execution of all
transactions, including but not limited to, transactions for purchase (including margin trading), investment in shares & securities, scrips, stocks, bonds,
debentures, mutual fund units, units of any collective investment scheme or any other security or financial instrument, derivatives, including but not
limited to, Equity Derivatives, Currency Derivatives, Interest Rates Derivatives, Commodities Derivatives, Commodities F&O, Securities and Lending
Borrowing Mechanism (SLBM), forwards, futures, REITS, INVITS, swaps and options, purchase, sale, investment, subscription of Public Provident Fund,
National Savings Schemes, New Pension System / Scheme and other savings schemes of Government of India or other undertakings, transactions for
payment to allowable billing companies, Fixed Deposits, Life Insurance, General Insurance or order for purchase or application for any offer or public issue
of shares, open offers made by the issuers, right issues made by Issuers, transactions for securities lending & borrowing system (hereinafter referred to
as "Purpose” ), I/We am/are hereby appointing ICICI Securities as my/our mandate holder and authorize ICICI Securities for the following :
1. To operate, block and/or debit the above mentioned Bank Account as per my instructions to ICICI Securities furnished in any manner acceptable
to ICICI Securities, to meet all my obligations in terms of the rights and obligation document for transactions done on National Stock Exchange
of India Limited (NSE) & Bombay Stock Exchange Limited (BSE), or any other recognized Stock Exchange by transferring the funds to designated
bank accounts of ICICI Securities Ltd as mentioned in Annexure 1 or any other bank account/s of ICICI Securities Ltd as may be notified by ICICI
Securities Limited on its website to me from time to time on my instructions and to give other instructions relating to the Bank Account(s), for
any matter concerning the above mentioned Purpose, including charges for account opening and availing of various services and facilities from
ICICI Securities.
2. To credit/debit the Bank Account(s) with monies received from /delivered by ICICI Securities erroneously on my/our behalf.
3. To debit my/our Bank Account(s) towards monies / fees /charges etc. due to ICICI Securities, ICICI Bank and to discharge all obligation in this
regard on my/ our behalf to ICICI Securities, ICICI Bank.
4. To debit/credit my/our Bank Account(s) towards monies/fees/charges etc. payable to ICICI Securities, ICICI Bank and/or to a Third Party Product /
Service Provider or to any of the affiliates/subsidiaries of ICICI Securities / ICICI Bank by virtue of I/we using/ subscribing to any of the facilities/
services provided either by ICICI Securities, ICICI Bank, or by a Third Party Product/ Service Provider or by any of the affiliates / subsidiaries of
ICICI Securities /ICICI Bank.
5. To receive my/our bank transaction statements, either in a physical copy format or a format which can be uploaded in system, from time to time.
6. To create the first and paramount lien on the Bank Account to exercise such lien in the event of any loss suffered/ costs incurred on account of
any transaction done / executed as per my/our instructions or as per the terms and conditions of the products/services availed of by me/us.

1This document is voluntary. However, the same is required to be executed by the customers in order to avail of seamless trading platform with
integrated bank account, demat account and broking account. If you do not wish to use the services of ICICI Bank Limited and ICICI Securities
Limited, you need not execute such documents.

Continued
I//We hereby agree and confirm that this mandate letter shall be canceled or revoked by furnishing a written intimation of the cancellation/revocation
request to ICICI Securities and due intimation to ICICI Bank, which request shall bear an acknowledgment. I/We further agree and confirm that
this mandate letter will be revoked / cancelled only after fulfillment of my/our obligation pertaining to unsettled transactions and outstanding dues
payable to ICICI Securities /ICICI Bank Limited/ and/or t or to a Third Party Product/Service provider or to any of their affiliates/subsidiaries as per the
terms and-conditions of the services/products availed by me/us.

Customer Signature(s) (To be digitally signed by account holders)

CC: ICICI Securities Limited

Annexure 1
Accounts of ICICI Securities
Bank Accounts:

A] Client Bank Account ICICI Bank Limited Account Number 000405034126, 000405072995, 000405005970, 000405005406,
000405008178, 000405100961, 000405101438, 000405074806, 000405072227, 000405100960, 000405106707 , 000405072670, 000405070670,
000405103343, 000405110876, 000405110635, 000405071200, 000405070810, 000405116455, 000405116456, 000405117017, 000405117015,
000405117019, 000405117020, Kotak Mahindra Bank Limited Account Number 5811824739, 000405120531, 000405111850, 00010017201536,
000405120529

B] Settlement Bank Account

ICICI Bank Limited Account No: 000405009257, 000405009258, 000405010710, 000405010655,000405070671, 000405110913, 000405117018

eDIS Mandate:
I understand that the accounts will be operated under the eDIS model offered by NSDL till such time the executed Power of Attorney ('POA') is taken on
record and updated against my account. Further, I hereby agree and accord my consent that subsequent to getting redirected to the website of NSDL from
ICICIdirect.com, entering the OTP and successful validation by NSDL under the eDIS model, ICICI Securities Ltd shall be authorized to debit the eligible
securities from my linked demat account.

Signature of 1st Applicant Signature of 2nd co-holder Signature of 3rd co-holder

 KRA KYC FORM
Account Opening Form (For Individuals Only) Know your Client (KYC) KYC Mode.: KRA Verified DigiLocker
Aadhar XML

Application No.: 5208939364

Please fill in ENGLISH and in BLOCK LETTERS
 A. Identity Details (please see guidelines overleaf)
1. Name of Applicant (As appearing in supporting identification document).
Name LIPINA BEHERA
PHOTOGRAPH
Maiden Name (If any)
Father’s Name MANGULI BEHERA Please affix
Spouse Name the recent passport
size photograph and
Mother’s Name
sign across it
2. Gender Male Female Transgender B. Marital status Single Married Others
C. Date of Birth 14-APR-1994 3. Nationality Indian Other
4. Status Please tick (3 ) Resident Individual Non Resident Foreign National (Passport Copy Mandatory for NRIs & Foreign Nationals)
Person of Indian Origin
*5. PAN GQFPB2552B Please enclose a duly attested copy of your PAN Card
6. GST No. (Pls provide GST registration certificate)

 B. Address Details (please see guidelines overleaf)

1. Address for Correspondence
BASELIHATA ,BALIJHARI ,BALIJHARI ,CUTTACK ,ODISHA

City / Town / Village CUTTACK District CUTTACK Pin Code 754037

State ODISHA Country INDIA
2. Contact Details
Tel. (Off.) (ISD) (STD) Tel. (Res.) (ISD) (STD)
Mobile (ISD) (STD) 9937201340 Fax (ISD) (STD)
Email ID [email protected]
I here by declare that the mobile number mentioned above belongs to: Self Spouse Dependent Parent Dependent Children
I here by declare that the Email ID mentioned above belongs to: Self Spouse Dependent Parent Dependent Children
3. Proof of address to be provided by applicant. Please submit ANY ONE of the following valid documents & tick (3 ) against the document attached
Passport UID (Aadhaar) Narega Job Card Driving License *Latest Gas Bill *Voter Identity Card *Latest Electricity Bill
*Latest Bank A/c Statement/Passbook *Latest Telephone Bill (only Land Line) Others (please specify)
* Not more thant 2 Months old. Validity/Expiry date of proof of address submitted
4. Permanent Address of Resident Applicant if different from above B1
BASELIHATA ,BALIJHARI ,BALIJHARI ,CUTTACK ,ODISHA

City / Town / Village CUTTACK District CUTTACK Pin Code 754037

State ODISHA Country INDIA
Permanent Address Type Residential / Business Residential Business Registered Office Unspecified
5. Proof of address to be provided by Applicant. Please submit ANY ONE of the following valid documents & tick (3 ) against the document attached.
Passport UID (Aadhaar) Narega Job Card Driving License *Latest Gas Bill *Voter Identity Card *Latest Electricity Bill
*Latest Bank A/c Statement/Passbook *Latest Telephone Bill (only Land Line) Others (please specify)
* Not more thant 2 Months old. Validity/Expiry date of proof of address submitted
 DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my/our 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 misleading or misrepresenting, I am/we are aware that I/we may be held liable for it.
Place CUTTACK Date
SIGNATURE OF THE APPLICANT

ICICI Securities Ltd.

 PAN VERIFICATION RECORD
Permanent Account Number

GQFPB2552B
Name LIPINA BEHERA
Gender FEMALE
DOB 14/04/1994
Verified On 16/10/2022 16:30:22

Digitally Signed On:

16/10/2022 16:30:22 IST

Note:

1. This PAN data is verified by DigiLocker (https://digilocker.gov.in) as per data provided

by the issuing authority, Income Tax Department, Govt. of India.
2. This digitally signed verification document is valid as per the IT Act 2000 when used
electronically.

Powered by TCPDF (www.tcpdf.org)

AADHAAR XML CONVERTED PDF

Name LIPINA BEHERA

Gender F
Date of Birth 14-04-1994
Mobile
Email
Ref. Number 00669617be35c75db5ba87add7e1669d416ced7cdc
5a320fc19a8f282929ce71
Aadhaar No. xxxxxxxx0722
Address Baselihata ,Balijhari ,Balijhari ,Cuttack ,Odisha
,754037 ,India

Note: This document has been created from the UIDAI XML submitted by the Investor. Investor has
submitted this data with informed consent to ICICI Securities Ltd./ICICI Bank Ltd. as KYC proof for opening
ICICI Securities Trading and ICICI Bank Demat account.
Customer Name :LIPINA BEHERA

PAN No :GQFPB2552B

Signature as per our records