Know Your Client (KYC)

Intermediary
Application Form (For Individuals Only) CDSL VENTURES LIMITED
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Please fill the form in ENGLISH and in BLOCK letters

Fields marked * are mandatory Application Number:

+
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* ACHPJ9194R Please enclose a duly attested copy of your PAN Card
____________________________

Name* (same as ID proof) ISHWER SINGH JALE

Maiden Name+ (if any)
Fathers/Spouse’s Name* KUNDAN
Date of Birth* 04/04/1954
Gender* ✓ Male Female Transgender
Marital Status* Single ✓Married Recent passport size
Nationality* ✓ Indian Other Applicant Photo

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 3019

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: KUNDAN LAL JALE H.NO-1916
Line 2 SECTOR-14
Line3 HISAR
City/Town/Village* HISAR District* HISAR Pin Code* 125001
State* HARYANA Country* INDIA
Address Type* Residential/Business ✓Residential Business Registered Office Unspecified

Applicant e-SIGN

1
B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)
Line 1* S/O: KUNDAN LAL JALE H.NO-1916
Line 2
SECTOR-14
Line3
HISAR
City/
Town/Village* HISAR District* HISAR Pin Code* 125001
State* HARYANA 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 3019
XXXX XXXX __ __ __ __
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]
________________________________________________________________________________________
Mobile No. * _____
9416670910
____________________________
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.

16-11-2024
DATE: _________________________ (DD-MM-YYYY)
HISAR
PLACE: _______________________________________

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

Employee Signature and Stamp Institution Name and Stamp

2
 DigiLocker verified e-Aadhaar
This document is generated from verified Aadhaar XML obtained from DigiLocker with due user consent and authentication

Document type e-Aadhaar generated from DigiLocker verified Aadhaar XML XML verified

Generation date 2024-11-16T11:04:27.749+05:30 Download Date 2024-11-16T11:04:27.749+05:30

Masked Aadhaar number xxxxxxxx3019

Name Ishwer Singh Jale

Date of Birth 04/04/1954

Gender Male

C/O , S/O S/O: Kundan Lal Jale

Address
S/O: Kundan Lal Jale
H.No-1916
Sector-14
Hisar - 125001

Landmark Locality
Sector-14

City / District Hisar

Pin Code 125001 State Haryana

For Limited Circulation | CONFIDENTIAL