Know Your Client (KYC)

Application Form (For Individuals Only) CDSL VENTURES LIMITED

….Exploring New Horizons

Please fill the form in ENGLISH and in BLOCK letters

Fields marked * are mandatory Application Number: 1000689475

+
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* AVZPD3666P
____________________________
Please enclose a duly attested copy of your PAN Card

Name* (same as ID proof) BHAVIK SUDHIRBHAI DHOLAKIYA

Maiden Name+ (if any)
Fathers/Spouse’s Name* SUDHIRBHAI KAMALKANT DHOLAKIA
Date of Birth* 24/12/1992
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* ANUBHUTI,
Line 2 Kachchh
Line3
City/Town/Village* Bhuj Kachchh
District+ Pin Code* 370001
State* Gujarat 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* ANUBHUTI,
Line 2 Kachchh
Line3
City/
Town/Village* Bhuj District+ Kachchh Pin Code* 370001
State* Gujarat 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 __
8 __ 9 __
5 __ 0

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* [email protected]
________________________________________________________________________________________
9909727022
+91 ____________________________
Mobile No. * _____

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.

29-08-2023
DATE: _________________________ (DD-MM-YYYY)
MUMBAI
PLACE: _______________________________________

5. For Office Use Only

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

IPV Date 29-08-2023 ✔ Self certified document copies received (OVD)

True Copies of documents received (Attested)
Emp. Name Poonam Patil
AMC / Intermediary Name :
Emp. Code 100049
Emp. Designation KYC APPROVER

Employee Signature and Stamp Institution Name and Stamp

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Documents: Proof of Identity (if submitted)

Proof of Identity (PoI)

Name of Client: Bhavik Sudhirbhai Dholakiya

PAN of Client: AVZPD3666P

Signature of the Client:

🖋
Stamp and Seal
Please sign here ( Moneylicious Securities Private Limited )

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 DigiLocker verified e-Aadhaar

Reference Id: 66202b9a-ea31-4ab9-af4e-f1bfb489e79e

Photo:

Aadhaar Number: xxxxxxxx8590

Name: Bhavik Sudhirbhai Dholakiya

Date of Birth: 24/12/1992

Gender: Male

ANUBHUTI, Kachchh 370001 Gujarat India

Address:

Generated on: 29-08-2023

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