Know Your Client (KYC)

Intermediary
Application Form (For Individuals Only) CDSL VENTURES LIMITED
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….Exploring New Horizons

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* Please enclose a duly attested copy of your PAN Card
____________________________
MPKPK6950G

Name* (same as ID proof) BATHULA PRADEEP KUMAR

Maiden Name+ (if any)

Fathers/Spouse’s Name* VEERASWAMY
Date of Birth* 13-02-2004
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 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* 2-21/1
Line 2 VILLAGE MALAPALLI
Line3
City/Town/Village* CHIGURUMAMIDI District* CHIGURUMAMIDI Pin Code* 505467
State* TELANGANA Country* INDIA
Address Type* Residential/Business Residential Business Registered Office Unspecified

Applicant e-SIGN

Signed by: Bathula Pradeep Kumar

eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST

1
B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)
Line 1* 2-21/1
Line 2
VILLAGE MALAPALLI
Line3
City/
Town/Village* CHIGURUMAMIDI District* CHIGURUMAMIDI Pin Code* 505467
State* TELANGANA 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 __
2 __
6 __
2 __
8
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. * _____
+91 ____________________________
9908202933
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.
Signed by: Bathula Pradeep
I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be Kumar
validated against Aadhaar details. I/We hereby consent to sharing my/our masked
eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST
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.

03-01-2024
DATE: _________________________ (DD-MM-YYYY)
CHIGURUMAMIDI
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
NAVI
Emp. Designation

Employee Signature and Stamp Institution Name and Stamp

2
Proof of Identity / PAN (mandatory)

Signed by: Bathula Pradeep

Kumar
eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST

5
Proof of Address (mandatory)

Signed by: Bathula Pradeep

Kumar
eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST

6
Applicant Wet Signature Page (mandatory)

Signed by: Bathula Pradeep

Kumar
eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST

7
 ¼ããÀ¦ããè¾ã ¹ãÆãä¦ã¼ãîãä¦ã ‚ããõÀ ãäÌããä¶ã½ã¾ã ºããñ¡Ã
Securities and Exchange Board of India
Declaration Form for opting out of nomination
[Annexure A to SEBI circular No. SEBI/HO/IMD/IMD-II DOF3/P/CIR/2022/82 dated
June 15, 2022 on Nomination for Eligible Mutual Fund Unit Holder(s)]

To Date D D M M Y Y Y Y
0 3 0 1 2 0 2 4
Mutual Fund / AMC’s Name NAVI
Mutual Fund / AMC’s Address

Mutual Fund Folio Number

Sole / First Holder Name BATHULA PRADEEP KUMAR

Second Holder Name

Third Holder Name
I / We hereby confirm that I / We do not wish to appoint any nominee(s) for my mutual
fund units held in my / our mutual fund folio 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 issued by
Court or other such competent authority, based on the value of assets held in the mutual
fund folio.

Name and Signature of Unitholder(s)

Unitholder (1) Signature: _______________________ Name: _______________________

BATHULA PRADEEP KUMAR

Unitholder (2) Signature: _______________________ Name: _______________________

Unitholder (3) Signature: _______________________ Name: _______________________

Signed by: Bathula Pradeep Kumar

eSigned using Aadhaar (digio.in)
Date: 2024-01-03 21:09:12 IST

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