QUESTIONNAIRE FORM “Q”

Form to be filled in by applicant(s) for issue of Duplicate Certificate(s)

in respect of security/ies for which original certificate(s) is/are lost

Name of the Company: __________________________________________________________

______________________________________________________________________________________________
1) Full name of the holder and joint
holder(s),if any
(fill in Identical order)
_________________________________________________________________________________________________________________
2) Number and kind of securities
held by the holder(s)for which
duplicate certificate(s) is/are
being sought.
_________________________________________________________________________________________________________________
3) Distinctive numbers of the
security/ies In respect of which
certificate(s) is/are lost
(must tally with no given in item 2)
_________________________________________________________________________________________________________________
4) When did the holder(s) acquire
the security/ies in respect of which
certificate are lost ? (Quote at least approx date/period)
_________________________________________________________________________________________________________________
5) When were the certificate(s) lost
or found to be missing ? (Quote at least approx date/period)
_________________________________________________________________________________________________________________
6) Full statement of the circumstances
regarding loss of the above
certificate(s)
_________________________________________________________________________________________________________________
7) Where any signed transfer form(s)
accompanying the lost certificate(s) ? If your answer is YES, you must furnish the company with a
If so, give full particulars of the ‘Prohibitory Order’ form a competent court to stop transfer
transaction . of securities in the na me(s) of any other person(s)
_________________________________________________________________________________________________________________
8) Where the securities were sold/mortgaged/
pledged or otherwise disposed of either by
the holder/applicant or by any other person ?
If so give full particulars of transaction *
_________________________________________________________________________________________________________________
9) Was diligent search made for the missing
certificate(s) ?
_________________________________________________________________________________________________________________
10) If the Board of Directors of the Company FOR OFFICE USE ONLY
is prepared to issue duplicate certificate(s) ________________________
is/are the applicant(s) prepared to fulfill the
conditions preliminary to the issue of duplicate
certificate(s) viz.(a)advertisement in the
Maharashtra government Gazette(b) In one
daily News Paper( c) one daily vernacular
newspaper circulating in Bombay (d) Execution ________________________
of indemnity with approved surety/ies SIGNATURE CHECKED BY
_______________________________________________________________________________________________________________
_____________________________________________ __________________________________
_____________________________________________ _________________ _________________
____________________________PIN______________ SIGNATURE(S) OF THE APPLICANT(S)
 (RS. 100/- STAMP PAPER)

AFFIDAVIT “A”
I/We ____________________________________________________________________________________________________
(Full name(s) of applicant(s)
solemnly affirm and say that what is stated in answer to the question on the form on the reverse
and marked “Q” is true to my/our knowledge.
DATE ______________________________ __________________________________
__________________________________
__________________________________
SIGNATURE(S) OF THE APPLICANT(S)

Solemnly affirmed at _________________________________________________ on the _________________

day of _______________________20___________________

Full Name and___________________________________

Address of _____________________________________
Magistrate/
Notary _______________________________________ _______________________________
_______________________________________ (Signature of Magistrate/Notary)

Regn No __________________________________

Use space below to affix

Notorial/Court Fee Stamp Official Seal of Magistrate/Notary
 (RS. 200/- STAMP PAPER)

INDEMNITY “I”
To ____________________________________________________________________________
(Name of the Company)
__________________________________________________________________.

WHEREAS
1. I/We _______________________________________________________________________
(Name(s) of Holder(s)/applicant(s)
____________________________________________________________________________
registered in the Register of Member and other books of _______________________________
(Name of the Company)
is the holder of **(refer item 2 of Q) ______________Shares/Bonds/Debentures of the
Company bearing Folio no., Certificate no(s)., and Distinctive No(s).______________________
_____________________________________________________________________________
2. It has been stated to the Company that the Certificate(s) of the said securities has/have been lost
mislaid and the same cannot be found ______________________________________________
_____________________________________________________________________________
3. I/We ________________________________________________________________________
______________________________________________________________________has/have
applied to the company for duplicate Certificate(s).
We * _______________________________________________________________________
____________________________________________________________________________
and (Name of the surety)________________________________________________________________________________________
for ourselves our respective heirs, executors and administrators do hereby jointly and severally
covenant with the company its successors and assigns that we and our heirs executors
and administrators respectively will at all times and from time to time save defend and keep
harmless and indemnified the company its successors and assigns and the Director and Officers
thereof and their respective heirs executors and administrators and their and each of their estates
and effects from against all actions causes suits proceedings accounts Claims and demands
whatsoever on account of the said security/ies or any of them or the loss non-production of the
Certificates their of on the part of any person or persons whomsoever and against all damages costs
charges and we said *__________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
and _________________________________________________________________________
undertake on demand by the company to return and re-deliver such duplicate Certificate(s) and
without such demand to produce and returned to the company the original Certificate(s) when
found or traced and to take all actions suits proceedings at our own cost as the Company shall
require for the recovery thereof or otherwise in relation to the premises.
Dated this_________________day of ____________/20___________.
Signed in presence of _____________________________________
____________________________________
________________________ (signature(s)of holder(s) /Applicant(s)
Signature of Magistrate/Notary
Full Name and Address of Magistrate/Notary
____________________________________ _____________________________________
____________________________________ Name, Address & Signature of Surety

_____________________________________
Name, Address & Signature of Witness
 SURETY FORM “S”
(FORM TO BE SIGNED BY SURETY PRUPOSED AGRIMENT)

PRIVATE &CONFIDENTIAL
Name of Surety:_______________________________________________________________________
(In Full)
Permanent Residential __________________________________________________________________
Address :__________________________________________________________________
__________________________________________________________________
_________________________________________pin______________________
Age: Years Permanent Income Tax No.:
A person cannot stand as surety for spouse/family member.
(fill in any one or more of the following boxes, whichever is applicable)

A Details of employment
1. Name of employer______________________________________________________________
2. Place of employment____________________________________________________________
____________________________________________________________
____________________________________________________________
3. Annual Salary :________________________________________________________________
4. Other emoluments :_____________________________________________________________
AND/OR
B Details of immovable property owned
(absoulutely in own name and not as a member of a joint & undivided Hindu family. Specify whether consisting of houses or more lands)
1. Within Municipal Limits : ______________________________________________________
2. Situation :____________________________________________________________________
____________________________________________________________________
3. Value : ____________________________________________________________________
4. Annual rent realized :__________________________________________________________
AND/OR
C Details of business owned
(absolutely in own name and not as a partner)

1. Nature of business and location ___________________________________________________

2. Annual turnover _______________________________________________________________
3. Annual profits ________________________________________________________________
________________________________________________________________
Date _________________20___________ _________________________
(Signature of the surety)

Witnessed by
Full Name And Address of Bank Manager/Employer
__________________________________________
__________________________________________ __________________________
__________________________PIN_____________ (Bank Manager/Employer)
N.B: Please note that Surety should own property in his own name and not as a member of a joint
and undivided Hindu family, or own business absolutely in his own name and not as a
partner.

If the Surety proposed is not a salaried employee, copy of the latest Assessment Order passed
by Income Tax Authorities should be enclosed with this form.

If the Surety proposed is only Landlord or property owner, Proposed Valuation Report issued
by Revenue Authorities/Municipal Authorities should be enclosed with the form.

Surety should not be related to the shareholder.