application form no. : acknowledgement i - icici...

I acknowledge receiving from Mr. / Ms.____________________________________________________________ the

required documents for opening 3 in 1 account ( Bank Account , Demat Account of ICICI Bank Limited & Trading

Account of ICICI Securities Ltd.). I have received cheque of ` ___________ towards account opening fees

charged only for opening trading account with ICICI Securities Ltd, vide Cheque no

_______________________________ dated

Date : ICICI Bank Limited (Depository Participant *) / ICICI Securities Ltd.

Stamp & signature of Official*Participant Name - ICICI Bank Limited, Address - ICICI Bank Demat Services, C/o. 3i infotech limited, Akruti Tradecentre, 3rd Floor, P.10, Road No.7, MIDC Marol, Bhim Nagar, Andheri (EAST), Mumbai- 400093, INDIA. DP ID - NSDLIN303028, CDSL 16014301Note: Please note that this acknowledgment does not constitute automatic acceptance of the documents andplaces no obligation than the submission of the indicated documents to ICICI Securities Ltd / ICICI Bank Ltd.Note: If the form is invalidated for any reason, ICICI is under no obligation to return the same to the applicant(s).

ACKNOWLEDGEMENT

Application Form No. :

The scanned copy of your filled form will be uploaded after your account has been opened.To view the form,please log in to your account and visit the Customer Service section >> My Profile >> My Account OpeningForm in the 'My Account' section.

View Your Application Online

Ahmedabad: 3355 1122 Andhra Pradesh: 8099551122 Assam : 9508551122 Shimla : 3355 1122

Banglore : 3355 1122 Bhopal : 3355 112 Bhubaneswar : 3355 112 Tamilnadu : 7305551122

Bihar & Jharkhand: 9835551122 Chandigarh : 3355 112 Chattisgarh & MP : 9770551122 UP(E)-Lucknow : 3355 112

Chennai : 3355 1122 Dehradun : 3355 112 Delhi : 3355 1122 Uttranchal : 7505551122

Ernakulam : 3355 112 Goa : 8657551122 Gujrat : 8905551122 Uttar Pradesh : 7505551122

Gurgaon : 3355 112 Haryana : 7876551122 Himachal Pradesh: 9817551122 West Bengal : 9832551122

Hyderabad : 3355 1122 Jaipur : 3355 112 Karnataka : 7676551122

Jammu and Kashmir : 9018551122 Kerala : 8590551122 Kolkata : 3355 1122

Maharashtra : 8657551122 Mumbai : 3355 1122 North East : 950855 1122

Orissa : 8260551122 Panaji : 3355 112 Patna : 3355 112

Punjab : 8591551122 Raipur : 3355 1122 Ranchi : 3355 112

CUSTOMER CARE CONTACT NUMBERS (Whom to contact List)

View the status application online at http//:www.icicidirect.com under the link “Check ApplicationStatus” under New User Section on the Customer Service page.

See Your Application Status Online

Version 51

1. This is an important document. Please ensure that it is filled in your presence in Black Ink.

2. The Account Opening form has been divided into 3 parts - PART A, PART B and PART C

3. 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 and PART C of the Form.

Account Opening Form(For Resident Individuals only) Inclusive of Savings Bank andDemat Account Opening Forms

AGENT/BROKER CODE : _______________________

KYC CAT CODE : _______________________

BANK/TL/SM/SUB AGENT CODE :_______________

ANNEXURE FORM : _______________________

OTHER CODE : ______________(Salary Team)

For Office Use Only

FORM TYPE : E INVEST

ERS ONLINE

SUB BROKER

Individual Others __________________

(please specify)

LEAD NUMBER :

CHANNEL : ___________________________

(Channel sales/Centre sales/RCLG sales/IBG/DSA/others)

H H_______________ (Bank Team)

Match No : _______________________

BB CODE (Bank Branch code)

PPA CODE ________________________________________________

B B

PREFERRED CONTACT TIME :

am / pmBetween

OR am / pm

1

IMPORTANT INSTRUCTIONS

1. Please ensure that your name as mentioned in the Form matches exactly with that mentioned onthe PAN. If there is a mismatch, please ask our sales executive to guide you on further formalities.2. Please do not give any blank cheques or cash to the sales executive. 3.Please ensure to countersign against cancellations/overwriting, if any, on the form. 4. Please ensure that you are aware ofall the terms and conditions applicable to your bank account and demat account. 5. Driving licenseof Maharashtra state can not be accepted as Address Proof. 6. Driving License of UP State can notbe accepted as address proof if it is handwritten. 7. Driving License of Delhi can not be accepted asaddress proof if it mentions " Not Valid for Residence Proof" 8.Your online account displays detailsof all the transactions entered in your account. 9.The account gives you an independent tool toview your details on a daily basis without having to depend on emails / correspondences from I-Sec, which may come after a lag. 10.Please ensure to login into your trading account regularly byusing your user id and password provided to you. 11. Please reconcile the transactions displayedin your account to ensure that all the transactions are as per your knowledge or as confirmed byyour sub broker / dealer (in case you are availing such services) 12. Never disclose / share User idand password of your trading account with any body. Never respond to any I have read and takennote of the above important instructions.communication seeking your User id and password. 13.Please note that you need not issue cheque / Transfer Instruction For Delivery (TIFD) slip for doingtransactions through icicidirect.com. Please do not give any blank cheque / TIFD slip to / in favourof anyone; not even the sales executive / sub broker / Authorised Person or any other official ofICICI Securities Ltd. 14. Always update your recent address, phone number and email id to ensurethat you receive all correspondences from I-Sec. 15. For Opening New Bank Account the accept-able address proofs are Aadhar Card, Voter ID , Passport , & Driving License.16. You can view standard account opening documents on www.icicidirect.com > customer service> useful links > Client Registration Documents in Vernacular Language.

PLEASE AFFIX

ACKNOWLEDGMENT FOR

WEB I-KIT

Please Affix Customer Visiting Card

2

This Email ID

Email ID

Personal / Primary Email ID

Office / Secondary Email ID

+ X Signature of 1st Applicant2 2nd Holder in Bank 3rd Holder in Bank

Cash Deposit Upto 1Lacs 1Lacs<10Lacs >= 10Lacs

Non Cash Deposit Upto 1Lacs 1Lacs<10Lacs >= 10Lacs

Cash Withdrawals Upto 1Lacs 1Lacs<10Lacs >= 10Lacs

Non Cash Withdrawals Upto 1Lacs 1Lacs<10Lacs >= 10Lacs

Foreign Inward Remittances NiL 1Lacs<10Lacs >= 10Lacs

Foreign Outward Remittances NiL Upto 10Lacs >= 10Lacs

Source of Funds Salary Business income Agriculture

Investment Inheritance Rent

Pension Funds from family members

Others (Please specify) ............................................

Remittance Purpose :.........................................................

(mandatory for remittance card account)

EXPECTED VALUE OF TRANSACTION IN A MONTH (Rs.)

SECTION 1 : ICICIdirect.com Account Details

USER ID : (It should be 6, 8 characters) (As registered on site or preferred user ID)

Account Reference Number (ARN) :

I have registered myself on ICICIdirect.com website for opening an ICICIdirect.com account including bank and demat accounts. The USER ID and passwordfor this account has been selected by me at the time of registration and I undertake to keep the password confidential. I am aware that fresh password would be issued tome after the above account is opened and I would be able to access my account with the fresh password only.

I/ We understand that existing Quantum Optima or Money Multiplier facility for fixed deposits, if any will be discontinued in this bank account. I/We further confirm to delinkexisting linked FDs, if any from my / our saving account. I/ We understand that henceforth these existing FDs will not be linked to saving account and will not get closedautomatically whenever there is shortfall in saving bank balance. I/We also authorize that the existing bank details and details under existing cust ID to be modified as per thisapplication.

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 linkmy Existing Saving Bank Account :# Existing Saving Bank A/C No: __________________________________________________________ IFSC Code _________________________________#BranchAddress:_______________________________________________________________________ MICR Number ________________________________________________________________________________________________________________

D D M M Y Y Y Y

(*Net Worth should not be older than 1 year)

P

Occupation (Please tick ( ) any one and give brief details):

Private Sector Service Public Sector

Government Service Business Professional

Self Employed Retired Housewife Student

Not Categorised

Gross Annual Income Details Please Tick ( ):

<1 Lac 1-5 lac 5-10 lac 10-25 lac >25 lacs

or Net-worth in `̀̀̀̀ ____________________________________

as on (date)

BSR CODE :_____________________________________ Whether you wish to receive physical contract note or Electronic Contract Note (ECN) (please tick)

Physical

ECN

SECTION 2 : Bank Account Details

However, I also currently hold .......................................................

Bank account(s) with ICICI Bank.

Account No.1

Account No.2

Account No.3

# Category : Individual SC ST OBC Others

# Account Type : Sole Applicant Joint Account

I wish to open a Saving Bank Account

Branch Code :

# Name of ICICI Bank Branch : .........................................................

(i) We (ICICI Bank Limited, its group companies, agents, representatives) would like tokeep our customers updated on the latest marketing offers. Please help us to serve youbetter by giving your consent to receive such information.

(a) I consent / do not consent to receive such informantion through SMS alerts.

(b) I consent / do not consent to receive such informantion through Phone calls.

(ii) I authorise / do not authorise ICICI Bank to exchange, share or part with all theinformation/ data provided herein including personal and business information with ICICIgroup companies / other institutions / such other persons as may be necessary / requiredfor the purpose of, including but not limited to, marketing, cross selling of various productsand sevices etc. to me/us, use or process the aforesaid information / data by such person/s, or furnishing of the processed information / data / products tereof to other Banks/institutions / other persons as may be necessary, and I shall not hold ICICI Bank liable inconnection with the use of such information or otherwise.

IMPORTANT CUSTOMER DECLARATION (PLEASE TICK REQUIRED OPTIONS)

Phone / Mobile Banking

9 Digit code number of the bank and branch appearing on MICR cheque issued by the bank :

MOTHER'S MAIDEN NAME :

(This would be used to identify you over the phone for PhoneBanking. PhoneBanking available in selected cities only)

Mode of Operation

Single Either or Survivor Anyone or Survivor

Debit Card

2. In case first applicant is not having an existing saving bank account, he would be allotted Debit Card compulsorily.

I wish to apply for a Debit Card (Second Holder) Yes No I wish to apply for a Debit Card (Third Holder) Yes No

1. If Applicant is already having an existing Saving Bank Account with ICICI Bank, a Debit Card will not be issued to the new Saving Bank Account. However, the Applicant can linkthe new Saving Bank Account to the Debit Card of the existing Saving Bank Account by calling up our call center or visiting the nearest branch.

Please tick applicable 1st Holder

Politically Exposed Person

Related to a politically Exposed Person

I am not Politically Exposed Person neither

I am Related to a politically Exposed Person

(For defination of PEP, Please refer part C)

Personal Details of Joint Applicants

Second Holder Name:............................................................................Sex : Male Female Blood Relative : Yes No

Date of Birth :

Third Holder Name:...............................................................................Sex : Male Female Blood Relative : Yes No

Date of Birth :

D D M M Y Y Y Ycannot be a minor

D D M M Y Y Y Ycannot be a minor

ADDRESS FOR CORPORATE BENEFITS

Permanent Address : Correspondence Address : P

Note: If opted Joint Holders, provied Joint Holder details in page 8& 9.

KRA KYC Compliant : Yes No C KYC Compliant: Yes No

Education : NonMatric SSC/HSC Under Graduate

Graduate Post Graduate

Professional

Type of Profession : Doctor CA/CS Lawyer Architect Consultant Engineer Trader Others .......

Nature of Business : Manufacturing Trading Services Retailing Agriculture Stock Broker Real Estate Others

..

4

If status code is blank, by defult MAB will be 5000/-`̀̀̀̀

Status code :_____________

Name of the Employer (Organization Name) :

Employed Since :

Establishment Name :

Employer’s / Office Address :

City : State : Pincode : Country

Tel.: Fax/TelexNo.: Designation :

If salaried employed with Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector Government

Multinational Others

Investment / Trading Experience _________ years in stock,________________ years in Derivatives, ______________ years in any other

investment related field.

If client is dealing through the sub-broker / AP , provide the following details:

Sub-broker’s / AP Name:

SEBI / Stock Exchange Registration number:

Registered office address:

Ph: Fax: Website:

Whether dealing with any other stock broker/sub-broker (in case dealing with multiple stock brokers/sub-brokers, provide details of all)

If registered with multiple members, provide details of all.

Name of Broker : SEBI Reg. No. :

Registered Office Address :

Name of sub broker (if any):

Name of Exchange : Client Code No.:

Details of disputes/dues pending from/to such stock broker/sub- broker:

Details of any action/proceedings initiated/pending/ taken by SEBI/ Stock exchange/any other authority against the applicant/constituent

during the last 3 years: ________________________________________________________________________________________________________________

INTRODUCER DETAILS (optional)

Name of the Introducer:

(Surname) (Name) (Middle Name)

Status of the Introducer: Sub-broker/Remisier/Authorized Person/Existing Client/Others, please specify

Cust id : Contact Number:

Address of the Introducer:

Signature of the Introducer: ____________________________

Details of the First ApplicantM

and

ato

ry fo

r S

ub

bro

ker cu

stm

ers

FA

TC

A

Primary Source of Wealth:

Salary Business Gift Royalty Rental Income

Prize money Ancestral property Others ____________________________

Are you a US Person Yes No

Please specify your country of Birth India US Others ___________

Place (City/Town) of Birth (if other than India) : _______________________

Citizenship: India U.S Other ___________________________Whether Tax Resident in any country other than India : Yes No

If Yes Please fill details asked in below - BLOCK

Country of Residence for Tax Purpose Tax Identification No. (TIN) or Type of No. Please specify FE Type/ Name(other than India) / TIN issuing country functional equivalent (FE) of TIN (Not applicable if TIN provided)

TIN FETIN FE

Address in the foreign country of which you are a tax resident (Other than India):

________________________________________________________________

City/Town/Village________________ State_____________________________

Pin Code________________ Country__________________________________

If you satisfy the criteria as mentioned above but do not have TIN / FE, please fillthe following details:

Country Name No. other than TIN / FE Type of No.

VISA Resident No.Work permit no. Dependent VISAStudent VISA Seafarer status

Going to the country ofresidence for first time*

*TIN or Functional Equivalent number to be communicated to ICICI Bankwithin 90 days, else Bank account may get closed.

5

SECTION 3 : Demat Account Details

You can link upto four Demat Accounts to ICICIdirect.com Account. The First Applicant in this form should be the First Holder in all these account(s).1. Specify the Demat Account No. in the appropriate cell if you wish to link an existing demat account to your ICICIdirect.com Account.

Category : ( Please tick any one of the option - In case of more than 1 demat accountBSDA option is not available)

I wish to open new residential individual demat account in NSDL CDSL

REGULAR DEMAT ACCOUNT OR

BASIC SERVICE DEMAT ACCOUNT

# DEMAT STANDING INSTRUCTION

Whether the applicant is interested in receiving Demat / Bank transactions statement throughe-mail Yes No If YES, please provide your e-mail ID on page 3.

I/We authorise you to receive credits automatically into my/our a/c. Yes NoAccount to be operated through Power of Attorney (POA) Yes No

PPPPPPPPPP

Option for Issue of DIS booklet (please tick any one)

Option 1 I/We wish to receive the Delivery Instruction Slip (DIS) booklet

with account opening.

Option 2 I/We do not wish to receive the DIS booklet with account

opening. However, the DIS booklet should be issued to me/ us

immediately on my/ our request at any later date.

*I wish to designate the demat account to be opened vide this application

form under the Rajiv Gandhi Equity Savings Scheme (RGESS) for

availing tax benefits. As per given selection ( Only 1 Demat Account can

be selected)

If selected yes you need to submit duly signed form A.

Please note that - Eligible Securities credited in the RGESS Designated

Demat accounts will be subject to lockin as per income tax requirements.

Please Note - If Selected BSDA option, Please refer BSDA Benefits inPart C Letter of confirmation Page Number 73

Whether you wish to avail of the facility of internet trading/ wireless technology(please tick) Yes No PPPPP

TYPE OF ACCOUNT

of demat account

Type of accounts DP ID A/c Number RGESS *

Single Holder

Fist Applicant + A

First Applicant + B

First Applicant A + B

Combination If you wish to link demataccout please specify details

Opting for NewDemat Account

Select

Combinations

I wish to receive standard account opening documents in Physical or Electronic “Part C if given in CD select Electronic otherwise select Physical”

Whether you wish to avail of the facility of internet trading/ wireless technology(please tick) Yes No

6

+ X 8

Signature of 1st Applicant Signature of Co-Holder A in Demat Signature of Co-Holder B in Demat

No Nomination Declaration in Demat Account / AccountsThis declaration needs to be signed by those customers who do not wish to nominate anyone in demat.

This document is mandatory as per NSDL circular number NSDL/POLICY/2009/0004 dated January 9, 2009 & CDSL Circular number CDSL/OPS/DP/1424 dated January 15, 20091. As per NSDL / CDSL guidelines, I/We confirm that I/We have been explained about the benefits of nomination facility to my /our demataccount by the official.2. I also understand that in the event of my / our demise, the process of “Transmission” will have to be followed by the legal heir as per theguidelines of NSDL / CDSL by visiting the nearest branch offering Demat Services.

3. Request you to kindly process my / our account opening form without the nomination facility.

Trading Preference

Exchange Segments

National Stock Exchange (NSE)

Capital Market Future and Option

Signature of 1st Applicant Signature of 1st Applicant

Currency Derivative

Signature of 1st Applicant

Bombay Stock Exchange (BSE)

Capital Market Future and Option

Signature of 1st Applicant Signature of 1st Applicant

+ X 3 + X 4

+ X 5

+ X 6 + X 7

If derivatives segment is selected, please submit any one of the financial documents as stated in page no 6. In absence of financial documentswe would be unable to activate your account for derivatives segment.

Financial Document Proof

Copy of Latest ITR Acknowledgement Latest Salary Slip not earlier than 3 months

Copy of Latest Annual Accounts (Balance Sheet & Profit & Loss A/c.) Copy of Bank account statement for last 6 months

Copy of Latest Net worth certificate Copy of demat account Holding statement.

Latest Form 16

PPPPP

SECTION 4 : NOMINATION FOR BANK ACCOUNT

Note : Nomination for Bank AccountNomination for Bank under section 45ZA of the Banking Regulation Act, 1949, & rule 2(1) ofthe Banking Companies (Nomination) Rules 1985 in respect of bank deposits.I/We nominate the following person who is entitled to receive money outstanding in my/ouraccount in the event of the death of the First Applicant or the death of all the Joint holders.In case application is made by Karta of HUF, Nomination can’t be made.This nomination is in accordance with the section 109 A of the Companies Act, 1956, andshall supersede any prior nomination made by me / us and also any testamentary documentexecuted by me / us.

Name : Mr./Mrs./Dr.

Relationship with the Applicant :

Date of Birth:

Address : Flat / Plot No. :

Bldg. /Society Name :

Road No./ Name :

Area / Locality :

City : Pin :

State :

D D M M Y Y Y Y

# FOR BANK ACCOUNT NOM. REG. NO.

Guardian Details (In case the nominee is a minor) As the nominee is a minor on this date, I/ Weappoint the Guardian (details provided hereunder) to receive the amount of the deposit onbehalf of the nominee in the event of my/our/minor’s death during the minority of the nominee.

Name : Mr./Mrs./Dr.

Relationship with the Applicant :

Address : Flat / Plot No. :

Bldg. /Society Name :

Road No./ Name :

Area / Locality :

City : Pin :

State :

IF THE EXISTING BANK A/C GIVEN FOR LINKING ALREADY HAS A NOMINATION,THE NEW NOMINATION ON THE AOF, WILL NOT BE UPDATED IN THE SB ACCOUNT

(To be signed by all the Holders in case a nomination has been made)

This document is mandatory as per RBI circular no. DBOD.No.Leg BC. 75 /09.07.005/2006-07 dated April05, 2007To,The ManagerICICI Bank LimitedBranch Name..............................................................................Branch Address..............................................................................................................................................................Dear Sir / Madam,

Providing Nomination to my / our Bank Account with ICICI Bank LtdType of Bank Account : Savings Bank Account

As per RBI guidelines, I / We confirm that I / we have been explained about the benefits of nominationfacility to my / our bank account by the official.

However, I / we state that inspite of the explanation of the said benefits, I / we do not wish to nominateany person to Savings Bank Account applied for by me vide this Application form bearingno_________________. Request you to kindly process my / our account opening form without thenomination facility.

Thanking you,

Yours truly,

In case of opening a new bank account, if you have not provided the nomination details, kindly sign the following letter. If you

have provided the nomination details, then please cancel this section

No Nomination Declaration in New Bank Account

+ X + XSignature of 1st Applicant Signature of Second Holder In Bank Signature of Third Holder in Bank+ X 10

+ X + XSignature of 1st Applicant Signature of Second Holder In Bank Signature of Third Holder in Bank+ X 9

Two Witness for the Nomination for Bank Account

Name : .....................................................................................

Address : .....................................................................................

Date ........................ Signature: + X .................................

Name : .....................................................................................

Address : .....................................................................................

Date ........................ Signature: + X .................................

7

# Joint Holder’s in Bank Account If Relevant

If you have opted to have a Joint Holder in your new bank account(s) then fill in his/her details below. If you do not wish to have a Joint holder, then please cancel this section.

Name of Joint Holder 1 : Mr./Mrs./Dr:

Maiden Name (f any)

Father’s Name :

Spouse Name :

Mother’s Name:

Correspondence Address : House / Flat No,: Floor Premise Name :

Street No.: Street Name Locality:

Landmark:. CIity/Town/Village: District :

Pin : State : Mobile : Fax : PAN

Tel. Off. : Tel.Res. : E-mail ID

Permenent Address : House / Flat No,: Floor Premise Name :



Pin : State : Blood Relative: Yes No Date of Birth :

Address Type Residential / Business Residential Business Registered Office Unspecified

Category: ST SC OBC Others Form 60 / Form 61 (Fill in Annexed form 60/61) Nationality, If other than Indian_______________________

KRA KYC Compliant : Yes No (If Yes, provide copy of letter provided by KRA) Relation with primary applicant ___________________________

C KYC Compliant : Yes No

SMS : YES NO Please tick, if applicable: Politically Exposed Person Related to a Politically Exposed Person

Marital Status Single Married Others Gender Male Female Transgender

Status Please tick ( ) Resident Individual No Resident Foreign National (Passport Copy Mandatory for NRIs & Foreign Nationals)

person of Indian Origin

Unique Identification Number (UID)/ Aadhaar, if any : Validity date of proof of Address

Know your customer document : 1. Identity Proof: 2. Current address proof:

3. Permenent Address Proof : Expiry Date :

Specify Proof of identity submitted for PAN exempt cases please tick ( ) : UID (Aadhaar) Passport Voter ID Driving Licence

Others................................................................................Any Others Information .............................................................................................................................

Financial Details of the Constituent : Gross Income range per annum : ` 0-5 Lac 5-10 lac 10-25 lac >25 lacs

or Net-worth in `̀̀̀̀ ____________________________________ as on (date)

If Salaried, employed with Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector Government Multinational Others

If Self Employed, and if in business, nature of Business Manufacturing Trading Services Retailing Agriculture Stock Broker Real

Estate Shroff/ Moneylenders If Professional, type of Profession Doctor CA/CS Lawyer Architect Consultant Engineer Others

If Others House Wife Retired Student If Agri Allied/ Farmer, Details of landholding Nil <=5 acres >5 acres

Education Under Graduate Graduate Post Graduate Professional Number of earning members in family : 1 2 >2

For office use only - BSR Code ___________________________









FA

TC

A


TIN FETIN FE


________________________________________________________________


Pin Code________________ Country__________________________________






8

4

cannot be a minor

(for future use only)

(only for ID Proof wherever Applicable)

4

FIRST NAME MIDDLE NAME LAST NAME

9

# Joint Holder’s in Bank Account If Relevant

If you have opted to have a Joint Holder in your new bank account(s) then fill in his/her details below. If you do not wish to have a Joint holder, then please cancel this section.

Name of Joint Holder 2 : Mr./Mrs./Dr:

Maiden Name (f any)

Father’s Name :

Spouse Name :

Mother’s Name:

Correspondence Address : House / Flat No,: Floor Premise Name :



Pin : State : Mobile : Fax : PAN

Tel. Off. : Tel.Res. : E-mail ID

Permenent Address : House / Flat No,: Floor Premise Name :



Pin : State : Blood Relative: Yes No Date of Birth :

Address Type Residential / Business Residential Business Registered Office Unspecified

Category: ST SC OBC Others Form 60 / Form 61 (Fill in Annexed form 60/61) Nationality, If other than Indian_______________________

KRA KYC Compliant : Yes No (If Yes, provide copy of letter provided by KRA) Relation with primary applicant ___________________________

C KYC Compliant : Yes No

SMS : YES NO Please tick, if applicable: Politically Exposed Person Related to a Politically Exposed Person

Marital Status Single Married Others Gender Male Female Transgender

Status Please tick ( ) Resident Individual No Resident Foreign National (Passport Copy Mandatory for NRIs & Foreign Nationals)

person of Indian Origin

Unique Identification Number (UID)/ Aadhaar, if any : Validity date of proof of Address

Know your customer document : 1. Identity Proof: 2. Current address proof:

3. Permenent Address Proof : Expiry Date :

Specify Proof of identity submitted for PAN exempt cases please tick ( ) : UID (Aadhaar) Passport Voter ID Driving Licence

Others................................................................................Any Others Information .............................................................................................................................

Financial Details of the Constituent : Gross Income range per annum : ` 0-5 Lac 5-10 lac 10-25 lac >25 lacs

or Net-worth in `̀̀̀̀ ____________________________________ as on (date)

If Salaried, employed with Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector Government Multinational Others

If Self Employed, and if in business, nature of Business Manufacturing Trading Services Retailing Agriculture Stock Broker Real

Estate Shroff/ Moneylenders If Professional, type of Profession Doctor CA/CS Lawyer Architect Consultant Engineer Others

If Others House Wife Retired Student If Agri Allied/ Farmer, Details of landholding Nil <=5 acres >5 acres

Education Under Graduate Graduate Post Graduate Professional Number of earning members in family : 1 2 >2

For office use only - BSR Code ___________________________









FA

TC

A


TIN FETIN FE


________________________________________________________________


Pin Code________________ Country__________________________________






4

cannot be a minor

(for future use only)

(only for ID Proof wherever Applicable)

4

FIRST NAME MIDDLE NAME LAST NAME

10

Notes for NSDL DP: 1. The nomination can be made only by individuals holding beneficiary owner accounts on their own behalf singly orjointly. Non- individuals including society, trust, body corporate and partnership firm, karta of Hindu Undivided Family, holder of power ofattorney cannot nominate. If the account is held jointly, all joint holders will sign the nomination form. 2. A minor can be nominated. In thatevent, the name and address of the Guardian of the minor nominee shall be provided by the beneficial owner 3. The Nominee(s) shall notbe a trust, society, body corporate, partnership firm, karta of Hindu Undivided Family or a power of Attorney holder. A non-resident Indian canbe a Nominee, subject to the exchange controls in force, from time to time. 4. Nomination in respect of the beneficiary owner account standsrescinded upon closure of the beneficiary owner account. Similarly, the nomination in respect of the securities shall stand terminated upontransfer of the securities. 5. Transfer of securities in favour of a Nominee(s) shall be valid discharge by the depository and the Participantagainst the legal heir. 6. The cancellation of nomination can be made by individuals only holding beneficiary owner accounts on their ownbehalf singly or jointly by the same persons who made the original nomination. Non- individuals including society, trust, body corporate andpartnership firm, karta of Hindu Undivided Family, holder of power of attorney cannot cancel the nomination. If the beneficiary owner accountis held jointly, all joint holders will sign the cancellation form. 7. On cancellation of the nomination, the nomination shall stand rescinded andthe depository shall not be under any obligation to transfer the securities in favour of the Nominee(s). 8. Nomination can be made upto threenominees in a demat account. In case of multiple nominees, the Client must specify the percentage of share for each nominee that shall totalupto hundred percent. In the event of the beneficiary owner not indicating any percentage of allocation/share for each of the nominees, thedefault option shall be to settle the claims equally amongst all the nominees. 9. On request of Substitution of existing nominees by thebeneficial owner, the earlier nomination shall stand rescinded. Hence, details of nominees mentioned in the from 10 at the time of substitutionwill be considered. Therefore please mention the complete details of all the nominees. 10. Copy of any proof of identity must be accompaniedby original for verification or duly attested by any entity authorized for attesting the documents, as provided in Annexure D. 11. Savings bankaccount details shall only be considered if the account is maintained with the same depository participant.

# NOMINATION / NO NOMINATION FOR DEMAT ACCOUNT (To be filled in by individual applying singly or jointly)

I/We nominate following persons who is / are entitled to receive security balances lying in my / our account, particulars where of are given below, in the event of my /our death.

Sr No. Nomination Details Nominee 1 Nominee 2 Nominee 3

1. 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

3. Fractional allocation of the securities

if any (pls tick the respective nominee,

(any one) if tick not marked default

will be first nominee)

4. Relationship With the Applicant*

(If Any)

5. Address of Nominee(s)

(Including City, State, Pin Code andCountry)

6. Mobile No.

Telephone no. of nominee (s) (with STD code)

FAX No.

7. Email ID of nominee(s)

8. 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. Demat Account ID

Sr Nos. 9 – 15 should be filled only if nominee (s) is a minor.

9. Date of Birth

10. Name of the Guardian of Nominee (Mr./Ms.)

First Name

Middle Name

Last Name

11. Address of Guardian of Nominee

(Including City, State, Pin Code andCountry)

12. Age of Guardian

13. Mobile No.

Telephone no. of nominee (s) (with STD code)

FAX No.

14. Email ID of Guardian

15. Relationship of Guardian with nominee

16. 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. Demat Account ID

+ X +X + XSignature of 1st Applicant Date ______________ Co-Holder A in Demat Date ____________ Co-Holder B in Demat Date __________11

Witness for the Nomination for Demat Account

Name : ............................................................................................................................................................................................................................................................

Address : ...........................................................................................................................................................................................................................................................

Date ........................ Signature: + X .................................

Type of accounts

Single Holder

Fist Applicant + A

First Applicant + B

First Applicant A + B

Nomination Details to be appliedto below combinationof

demat account

Opting for New

Demat Account

SelectCombinations

12. DP ID and Client ID shall be provided where demat details is required to be provided. (refer point no.8 – Nominee Identification details)Notes for CDSL DP: 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 timeto 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 liablefor termination and suitable action.

2.This nomination shall supersede any prior nomination made by me / us and also any testamentary document executed by me / us.

Email ID

11

This Email ID

12

Details of the Co-Holder

Please tick applicable Gross Anual Income details Occupation PEP



I am not Politically Exposed Person

Demat Co-holder A neither I am Related to a politically Exposed Person <1 Lac 1-5 lac 5-10 lac

10-25 lac >25 lacs


Government Service Business

Professional Agriculturist Retired

Housewife Student Forex Dealer

Others (Please Specify) ................................




Professional

Type of Profession : Doctor CA/CS Lawyer Architect

Consultant Engineer Trader Others .......

Nature of Business : Manufacturing Trading Services

Retailing Agriculture Stock Broker

Real Estate Others..









FA

TC

A


TIN FETIN FE


________________________________________________________________


Pin Code________________ Country__________________________________






Please tick applicable Gross Anual Income details Occupation PEP



I am not Politically Exposed Person

Demat Co-holder B neither I am Related to a politically Exposed Person <1 Lac 1-5 lac 5-10 lac

10-25 lac >25 lacs


Government Service Business

Professional Agriculturist Retired

Housewife Student Forex Dealer

Others (Please Specify) ................................




Professional

Type of Profession : Doctor CA/CS Lawyer Architect

Consultant Engineer Trader Others .......

Nature of Business : Manufacturing Trading Services

Retailing Agriculture Stock Broker

Real Estate Others..









FA

TC

A


TIN FETIN FE


________________________________________________________________


Pin Code________________ Country__________________________________






13

+X Signature of 1st Applicant

Signatures And Photographs :

Please affix a recent photograph. Please sign in black ink within the box.

Signature of Co-holder A in Demat

Name :

Signature of Co-holder B in Demat

Name :

Co-Holder A

Please paste latestPassport sizePhotograph

(Sign across the photo)

Co-Holder B



Signature of 3rd Holder in Bank

Name : Third Holder



Signature of 2nd Holder in Bank

Name : Second Holder



Name : # First applicant



KYC CERTIFICATION

FORM NO :

14

#FOR TRADING ACCOUNT

NOMINATION DETAILS (for individuals only)

I/We do not wish to nominate I/We wish to nominateName of the Nominee: .......................................................................................................................................................Relationship with the Nominee: ......................................................................PAN of Nominee: ...................................................................... Date of Birth of Nominee: ............................................ Address and phone no. of the Nominee: .................................................................................................................... ..................................................................... ..................................................................... ..................................................................... ........................................If Nominee is a minor, details of guardian:Name of guardian:...............................................................................................................................................................................................................................................................................................Address and phone no. of Guardian : ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Signature of guardian ...........................................................................

SECTION 5 : NOMINATION FOR TRADING ACCOUNT

Two Witness for the Nomination (Trading Account)

Name : ...................................................................................

Address : ...................................................................................

Date ........................ Signature: + X .................................

Name : ...................................................................................

Address : ...................................................................................

Date ........................ Signature: + X .................................

FOR OFFICE USE ONLY

Combinations ICICI Bank Demat A/c. No. Combinations ICICI Bank Demat A/c. No.

First Applicant / Karta First Applicant + B

First Applicant + A First Applicant +A+ B

Customer ID No. :

ICICI Bank Account No.:

Bank Account Opening Date :

Checked by DVU Official at RPC:

Date :

Signature ________________

FOR OFFICE USE ONLY

D D M M Y Y Y Y

PAYMENT DETAILS (Account Opening Fees)

Total Amount Payable Cheque Details

(` in words) (` in figures) No. ............................................. Date............................................. / 20.............................................

drawn on Bank............................................. ............................................. ............................................. ............................

9-Digit Code Number of the Bank and branch appearing on the MICR cheque issued by the Bank

Debit Note ______________________________________________________________

Bank Account No. ________________________________________________________

14

1. I hereby declare that the details furnished in the account opening form are true and correct to thebest 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 andunderstood the contents of the document on policy and procedures of the stock broker and the tariffsheet. 3. I further confirm having read and understood the contents of the Schedule of Charges,Rights and Obligations document, Risk Disclosure Document, Policies and Procedures and GuidanceNote I do hereby agree to be bound by such provisions as outlined in these documents. I have alsobeen informed that the standard set of documents has been displayed on www.icicidirect.com 4. Therules and regulation of the Depository Participants pertaining to an account which are in force nowhave been read by me/us and I have understood the same and I agree to abide by and to be bound bythe rules as are in force from time to time for such accounts. I/we acknowledge the receipt of copy ofthe document, “Rights and Obligations of the Beneficial Owner and Depository Participant”. Underpenalty of perjury, I certify that: 5 The applicant is (i) an applicant taxable as a US person under thelaws 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 issubject to U.S. federal income tax regardless of the source thereof. (This clause is applicable only ifthe account holder is identified as a US person) or 6. The applicant is taxable as a tax resident underthe laws of country outside India. (This clause is applicable only if the account holder is a tax residentoutside of India) 7. In case of any change in my Tax residency status on a future date, I undertake toinform I–Sec within 30days. I agree that if I am a U.S. Person or tax resident of a reportable foreignjurisdiction (other than U.S.) requiring reporting under FATCA/CRS or any other laws, my accountdetails, as required under Inter Governmental Agreement (IGA)/ Multilateral Competent AuthorityAgreement (MCAA) signed by Indian Government, would be reported by I-Sec to the relevant taxauthority. I hereby confirm that details as provided by me above can be shared by I-Sec with theconcerned Asset Management Companies (AMCs) or such other product providers, to whom FATCA/CRS norms are applicable, in whose schemes/ products I may invest/transact in future through I-Sec.Following clause applicable only if any of the indicia parameters is outside India and TIN/ FE is notavailable since not resident for tax purpose outside India OR Country of Birth is US and US person ismentioned as “No” in FATCA / CRS declaration I hereby confirm that I am not a US Person or aresident for tax purpose in any country other than India, though my Country of Birth suggests myrelation with US or one or more parameters suggest my relation with the country outside India. I amproviding / already provided copy of my PAN card to I-Sec and now providing a certificate ofrelinquishment of US citizenship (loss of nationality) OR reasons for not having such a certificatedespite relinquishing US citizenship OR for not obtaining US citizenship at birth (only if born in US)___________________________________________________________________________________________________8. I hereby consent to receive information from Central KYC Registry through SMS/Email on theregistered number/email address as mentioned in KYC form. I hereby confirm that details as providedby 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 anylaw. 9. I hereby authorise ICICI Securities Limited / ICICI Bank Ltd to fetch and download my detailsfrom Central KYC Registry. I also hereby authorise ICICI Securities Ltd / ICICI Bank to modify andupdate my existing details in Central KYC Registry with my latest KYC details provided account openingform. I / We declare that not providing details of mobile no and or email id in the account opening formshall be considered that I / We do not have same to provide.I have given cheque of ` ___________ towards account opening fees charged only for opening tradingaccount with ICICI Securities Ltd, vide Cheque no __________________ dated ____________Alternate PIN Code ___________________________ and City ________________________________ for branchmapping for custumer servicing.

FOR OFFICE USE ONLYUCC Code allotted to the Client: ____________________ CKYC No. ____________________________________

Particulars Documents verified with Client Interviewed In-PersonOriginals By Verification done by

Name of the Employee

Employee Code

Designation of the employee

Date

SignatureI / We undertake that we have made the client aware of ‘Policy and Procedures’, tariff sheet and all the non-mandatory documents. I/We have also made the client aware of ‘Rights and Obligations’ document (s), RDD andGuidance Note. I/We have given/sent him a copy of all the KYC documents. I/We undertake that any change inthe ‘Policy and Procedures’, tariff sheet and all the non-mandatory documents would be duly intimated to theclients. I/We also undertake that any change in the ‘Rights and Obligations’ and RDD would be made available onmy/our website, if any, for the information of the clients.I have met Mr. / Ms. ____________________________________________________________________ /JointHolder 1 in bank / Co-Holder A in Demat_____________________________________________/ Joint Holder 2 inbank / Co-Holder B in Demat_____________________________________________/ in person at his / her resi-dence / office / Others (please specify) _____________________________ and confirm that the form has been

signed by the applicant in my presence.

__________________________________ ____________Signature of the Authorised Signatory Date Stamp of ICICI Bank / ICICI Securities Ltd

DECLARATION

(The person who is doing IPV can also sign)

Signature of 1st Applicant

+ X

15 Signature of Co- Holder A in Demat Signature of Co- Holder B in Demat

Reason

15

CONDITIONS1. The value of shares and charges is calculated as per NSDL / CDSL formula and rates. 2. There will be a charge of ` 100 for dishonour of any cheque or unsuccessfulattempt to recover payment through direct debit or ECS. The depository services are liable for discontinuation, if ICICI Bank is unable to recover charges from thecustomer for any reason whatsoever. In such cases there will be a charge of `250 for resumption of services and the services will be resumed after a minimum of threeworking days from the date of receipt of request at Central Processing Office, Mumbai. 3. Any service that is not indicated above will be charged separately as per therates applicable from time to time. 4. Service Tax and other Government taxes, levies, etc. applicable as per the prevailing rates will be charged in addition to thesecharges. 5. As per regulatory guidelines, if you close/shift your demat account, the portion of the advance Annual Service Charge applicable to the balance quarter(s)will be refunded. This is with effect from July 1, 2010. 6. ICICI Bank reserves the right to revise the tariff structure from time to time and the same will be communicatedto the customers with a notice of 30 days. 7. No charges are payable for opening of Demat accounts.

+ X + XSignature of 1st Applicant Signature of Co-Holder A in Demat Signature of Co-Holder B in Demat+ X 16

16

Charge Regular Account Basic Services Demat Account (BSDA)Account Opening Nil NilAnnual Maintenance Charges ¹ 700 Holding value

Upto ` 50,000 – NIL From ` 50,001 -` 2,00,000 – ` 100 Above ` 2,00,000 Tariff of regular accounts.

Buy – Market and Off-Market Nil NilNil for Trades done at www.icicidirect.com Nil for Trades done at www.icicidirect.com

Sell – Market and Off-Market andRedemption of MF units(% of transaction value of each ISIN) –Max. ` 500 for debt instruments • 0.04% of value of securities (Min. ` 30 and Max ` 25,000) • 0.06% of value of securities (Min. ` 35 and Max ` 25,000)• Instruction submitted through Internet (E-inst / IVR) • 0.04% of value of securities (Min. ` 35 and Max ` 25,000) • 0.06% of value of securities (Min. ` 40 and Max ` 25,000)• Instruction submitted through Call Centre • 0.04% of value of securities (Min. ` 40 and Max ` 25,000) • 0.06% of value of securities (Min. ` 45 and Max ` 25,000)• Instruction submitted at Branches • Nil for Trades done at www.icicidirect.com • Nil for Trades done at www.icicidirect.com

Rejection/failure of Transfer InstructionFor Delivery (TIFD) ` 30 ` 30Extra charges for processing ofTIFDs submitted after the cut-off timing(% of transaction value)• Instruction submitted through Internet (E-inst / IVR) • Nil • Nil• Instruction submitted through Call Centre • Nil • Nil• Instruction submitted at Branches • ` 10 per ISIN • ` 10 per ISIN(accepted at Client’s risk)DematerialisationFor each request form ` 50 ` 50Extra for each certificate ` 3 ` 3Rematerialisation A fee of ` 25 for every hundred securities or part thereof A fee of ` 25 for every hundred securities or part thereof

subject to maximum fee of ` 3,00,000; or a flat fee of subject to maximum fee of ` 3,00,000; or a flat fee of` 25 per certificate, whichever is higher. ` 25 per certificate, whichever is higher.

Reconversion of MF units ` 25 Per Instruction ` 25 Per InstructionClosure of Account Nil NilPledge Creation / Closure / Confirmation / Invocation(% of value for each ISIN in each request)• If, ICICI Bank is counter party • 0.02% (Min. ` 35 and Max ` 25,000) • 0.04% (Min. ` 60 and Max ` 25,000)• If, ICICI Bank is not counter party • 0.04% (Min. ` 45 and Max ` 25,000) • 0.06% (Min. ` 60 and Max ` 25,000)Additional Account Statements ` 20 ` 20Reissuance of Delivery Instruction Slip(DIS) Booklet charge ` 50 per booklet ` 50 per bookletIn addtion to above NSDL/CDSL charges are applicable from time to time are recoverable

Sell-Market and Off-Market : NSDL - ` 4.5/- per debit instruction (Nil for commercial paper and short-term debt instructions): CDSL - ` 5.5/- per debit instruction (Nil for commercial paper and short-term debt instructions)

Remat Charges : NSDL - A fee of ` 10/- for every hundred securities or part thereof; subject to maximum fees of ` 500000/-, or flat fee of ` 10/- per certificate, Whichever is higher.: CDSL - A fee of ` 10/- for every hundred securities or part or a flat fee of thereof; subject to maximum fees of ` 500000/-, or a flat fee of ` 10/- per certificate, whichever is higher. However no fee shall be the collected in case of Goverment Securities and Mutul Fund units.

Reconversion of MF units into SoA : NSDL Rs 10 per instruction ; CDSL Flat fee of Rs. 5.50 per transaction. Redemption of MF units through Participants : NSDL Rs. 4.50 per instruction ; CDSL Flat fee of Rs. 5.50 per transaction.Pledge Creation : NSDL - ` 25/- per instruction

CDSL - ` 12/- per instructionPledge Closure : CDSL - ` 12/- per instruction

` plus applicable service tax payable at the time ofaccount opening and there afterevery year in the month inwhich theaccount was opened (waived for all ICICIdirect.comcustomer for the first year in which they open the account)

DEMAT FEE SCHEDULE

Schedule of Charges (Brokerage Plan)

A. Brokerage AccountPlease choose between any of the two brokerage plans for Capital Market - Delivery Transactions

I-Saver- A Variable brokerage plan for Delivery Transactions based on Volumes donein a quarter

I-Secure : A fixed brokerage plan irrespective of delivery volumes

Plans Cash Brokerage (Delivery)I-Saver Ranging from 0.25% to 0.75%I-Secure 0.55%

Brokerage rates in Margin, Margin Plus, Futures, Options and Currency SegmentProduct Brokerage % Brokerage % on 2nd

Leg Intra-day Square offMargin 0.03% to 0.05% 0.03% to 0.05%Margin Plus 0.03% to 0.05% 0.03% to 0.05%Equity Futures 0.03% to 0.05% 50 per lotEquity Options 35 to 95 per lot 50 per lotCurrency Futures 0.03% to 0.05% 10 per lot

I have also read and understood detailed schedule of charges provided in PART C of Account opening form

`

`

`

` `

1. Minimum balance All the new bank accounts opened will have to maintain requirement an average monthly balance of ` 5000/-. Failure to do so would result in a feeas per the regulation of ICICI Bank. 2. If trading account is closed or ICICI Bank account is de-linked, then you would have to maintain minimum balance as applicable tothe respective type of account with ICICI Bank 3.In case you avail any additional facility / service on the linked ICICI Bank account, then you agree to be bound by the termsand conditions and applicable charges for the relevant facility / service as mandated by ICICI Bank.

I-Secure - (Form version to be selected as 2 in ICIS) I-Saver – (Form Version to be selected as 3 in ICIS)

MANDATORY DOCUMENTS

Name of UM & AUM : ________________________________________________________________________________________________

Employee Number : Designation

At present working at : ________________________________________________________________________________________________

(Mention name of Branch)

I have understood the document and certify that the document convey compliance with KYC guidelines

This document is voluntary. Voluntary means that the document is not prescribed by Regulators, however the same is required by ICICI Securities Limited for offering the 3 in 1 account i.e. seamless trading platformwith integrated bank account, demat account and broking account. If you do not wish to avail the services of ICICI Bank Limited and ICICI Securities Limited, you need not execute such documents.

Account Number : _______________________________________________________ Cust Id : ___________________________________

(COMPULSORY) (as mentioned in the Welcome Kit)

Company working for : _______________________________________________________(COMPULSORY)

FORM A

Date :

Dear sir,

I, ______________________________________________________________________________hold a salary account with ICICI Bank.

The details of the same are as below

Please open my Savings Account, which would be for purpose of linking to ICICIdirect.com Trading

account, under the same Cust Id as that for the above-mentioned Salary Account.

IF THE DETAILS GIVEN ON FORM A AND THE DETAILS ON THE APPLICATION DO NOT TALLY,

KINDLY OPEN A NEW SAVING BANK ACCOUNT UNDER NEW CUST - ID

(Applicable for existing Salary Account customers who wish to open savings account linked to trading account under same Customer ID)

D D M M Y Y Y Y

Yours Truly,

To be filled in case the joint A/C holder in the Bank is a Blood relative(Blood relatives are defined as parents, spouse, children and siblings. Relationship documents as prescribed under LIST F of the form to be submitted.)

ANNEXURE -A

Declaration for Blood Relative – To be filled in by Primary applicant

Name of the Applicant

Name of the first joint Applicant

Name of the second Joint Applicant

ANNEXURE -BTo be filled in case the documents submitted are in Vernacular language.

Form 60 / 61 (to be filled by those who do not have PAN)

(To be filled if applicable for each Bank account holder seperately)

Relationship with primary Applicant :

Relationship with primary Applicant :

I solemnly affirm:

i. The relationship of Joint applicant’s with me

ii. The above Joint Applicant/s is/are blood relative/s spouse.

iii. That information given herein is correct and nothing has been concealed and I amaware it is illegal and criminal offense to deliberately furnish false information orsuppress information and

iv. That I undertake to be entirely responsible for any loss/expenses incurred by

ICICI Securities, ICICI Bank and its Group Companies on account of relying

on my declaration

v. This serves as identity and address proof for account opening.

Signature

NON MANDATORY DOCUMENTS

Signature of 1st Applicant18

Name : ___________________________________________

FORM No.60((See Second Proviso to rule 1148)Form of declaration to be filed by a person who does not have a permanent accountnumber and who enters into any transaction specified in rule 114B1. Full name & Address of the declarant _________________________________________________________________________________________________________2. Particulars of transaction ___________________________________________3. Amount of the transaction____________________________________________4. Are you assessed to tax?5. If Yes, (i) Details of Ward/Circle/Range where the last return of income was filed ___________________________________________ (ii) Reasons for not having permanent account number:__________________________________________________6. Details of the document being produced in support of address in column(1)

FORM No.61[See Proviso to Clause (a) of rule 114C(1)]Form of declaration to be filed by a person who has agricultural income and is not inreceipt of any other income chargeable to income-tax in respect of transactionsspecified rule 114B1. Full name & Address of the declarant _________________________________________________________________________________________________________2. Particulars of transaction ___________________________________________3. Details of the documents being produced in support ofaddress in column (1): Yes NoU hereby declare that my source of income is from agriculture and I am not requiredto pay other income, if any,

Date : _________________ Place : __________________

Signature of 1st Applicant19

VERIFICATION (To be filled along with from 60/61)I, _______________________________________________________________________ dohereby declare that what is stated above is true to the best of my knowledge and belief.Verified today, the ________________day of _____________Place :____________________Date : _____________________________________Introduction :Documents which can be produced in support of the address are :a. Ration Card b. Passport c. Driving licence d. Identity Card issued by any institution e. Copy ofthe electricity bill or telephone showing residential address f. Any document or communicationissued by any authority of the Central Government, State Government or local bodies showingresidential address g. Any other documentary evidence in support of his address given in thedeclaration

+X : Signature of 1st Applicant17

17

This document is voluntary. Voluntary means that the document is not prescribed by Regulators, however the same is required by ICICI Securities Limited for offering the3 in 1 account i.e. seamless trading platform with integrated bank account, demat account and broking account. If you do not wish to avail the services of ICICI Bank Limitedand ICICI Securities Limited, you need not execute such documents.

THIS IS TO CERTIFY THAT MR/MS/MRS. _________________________________________________

HAS MET ME PERSONALLY AND I HAVE VERIFIED ALL THE DOCUMENTS WITH THE ORIGINAL

PROOFS.

NAME OF APPLICANT IN THE IDENTITY PROOF IS ___________________________________________________ ,

ON RESIDENCE PROOF IS __________________________________________________________________________

AND ON APPLICATION IS ____________________________________________________________

ALL THE DETAILS ARE PROPER AND CORRECT BELONGING TO THE SAME APPLICANT.

REGION : ___________________________

NAME OF KYC CAT / ICICI BANK EMPLOYEE : ______________________________________________________

(SIGNA(SIGNA(SIGNA(SIGNA(SIGNATURE & STTURE & STTURE & STTURE & STTURE & STAMP)AMP)AMP)AMP)AMP)

EMP CODE : ________________________

DESIGNATION ______________________

DATE :___________________________

LETTER FOR NAME VARIATION (EXPANDED OR ABBREVIATED)

TO WHOM SO EVER IT MAY CONCERN

Date :

LIST OF CLOSED QUANTUM OPTIMA FDs BANK A/C :

FD A/C NUMBER TRANSACTION ID

AOF NO :

MAKER SIGN : MAKER EMP. NO.

CHECKER SIGN : CHECKER EMP. NO.

Local Rejection Reasons

S.No. Pg. No.

Rectified dateRECTIFIED

YES NO

REJECTION REASON

NON MANDATORY DOCUMENTS

+X : Signature of 1st Applicant20

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18