Know Your Client (KYC) PLEASE AFFIX A

RECENT PASSPORT
Application Form (For Individuals Only) PHOTOGRAPH AND

Please fill type the form in English and BLOCK letters. Sign all areas marked with SIGN ACROSS IT
‘x’. Once completed, please mail the completed form along with the necessary
proofs to our corporate office in Mumbai. CLIENTʼS SIGNATURE [1]

A. Identity Details (please see guidelines)

FULL NAME (As appearing in supporting identification document): Amit Prakash

FATHER / SPOUSE’S NAME: TEJ NARAYAN PRAKASH MAIDEN NAME: (If any)

MOTHER NAME:
GENDER ✔ MALE FEMALE T - TRANSGENDER MARITAL STATUS ✔ MARRIED UNMARRIED

CITIZENSHIP ✔ IN - INDIAN OTHER DATE OF BIRTH (dd/mm/yyyy) 07/09/1997

RESIDENTIAL STATUS ✔ RESIDENT INDIVIDUAL NON RESIDENT INDIAN FOREIGN NATIONAL PERSON OF INDIAN ORIGIN

PAN (Please enclose a duly attested copy) DSKPP9799G Applicant E-Sign

PROOF OF IDENTITY SUBMITTED FOR PAN EXEMPT CASES (Please Tick )

A- Aadhar Card XXXX XXXX

B- Passport Number
C- Voter ID
D - Driving License
E - NREGA Job Card
F - NPR
✔ z - Others PAN (any document by Central Government)

Identification Number

B. Address Details (Please see guidelines)

Address Type Residential / Business ✔ Residential Business Registered Office Unspecified
ADDRESS FOR RESIDENCE/CORRESPONDENCE:

55, IAS Colony Bailey Road Beside Maruti Showroom Danapur Cantt, Dinapur Cum Khagaul Danapur

CITY/TOWN/VILLAGE: PATNA STATE: BIHAR PIN CODE 801503

DISTRICT: PATNA COUNTRY: India

PERMANENT ADDRESS OF RESIDENT APPLICANT IF DIFFERENT FROM ABOVE B1 OR OVERSEAS ADDRESS(MANDATORY) FOR NON RESIDENT APPLICANT:

55, IAS Colony Bailey Road Beside Maruti Showroom Danapur Cantt, Dinapur Cum Khagaul Danapur

CITY/TOWN/VILLAGE: PATNA STATE: BIHAR PIN CODE 801503

DISTRICT: PATNA COUNTRY: India

PROOF OF ADDRESS* (attested copy of any 1 POA for correspondence and permanent address each to be submitted)

✔ A- Aadhar Card XXXX XXXX 6158

B- Passport Number Expiry Date

C- Voter ID
D - Driving License Expiry Date

E - NREGA Job Card

F - NPR
z - Others (any document by Central Government)

Identification Number

PAGE 1
V 3.1.0
 C. Contact Details (in CAPITAL)

EMAIL ID* [email protected]

MOBILE NO.* 8210796240

TEL (Off) TEL (Res)

D. Applicant Declaration

I/We hereby declare that the KYC details furnished by me are true and correct to the Applicant e-SIGN Applicant Wet Signature
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 the entire account opening form along with supporting
documents as applicable, with KRA and other Intermediaries with whom I have a
business relationship for KYC purposes only.

Place PATNA
Date
03/12/2024
FOR OFFICE USE ONLY IPV Done on (dd/mm/yyyy)
AMC/Intermediary name OR code
Application Typ
e eN w ✔ Update
(Originals verified) True copies of Seal/Stamp of the intermediary should contain
documents received KYC Number Staff Name
(Mandatory for KYC update request) Designation
Name of the Organization
Signature
(Attested) True copies of documents
Account Type Normal Small Date
received Main Intermediary Place
Simplified
KYC Mode* Normal EKYC OTP EKYC Biometric Online KYC Offline KYC ✔ Digilocker

DECLARATION FOR NAME MISMATCH

(To be filled if the name on documents is different)
This is to bring to your notice that my name is spelt differently in my Identity proof, Address proof and Bank proof. Please find below the
names as spelt in respective proofs:

Name as per Income Tax Amit Prakash

Name as per Bank Proof

Name as per Address Proof Amit Prakash

Name as per Income Proof

I hereby confirm that all the said names belong to me. I hereby state and confirm that what is stated above is true and correct information.
I agree to indemnify and keep Upstox Securities Pvt. Ltd. / RKSV Commodities India Pvt. Ltd. indemnified at all times from and against all costs,
charges, damages, penalties (including reasonable attorney fees) suffered and/or incurred by Upstox Securities Pvt. Ltd. / RKSV Commodities
India Pvt. Ltd. for any act done or omitted to be done on the above declaration.

CLIENTʼS SIGNATURE [12 ] X

PAGE 2
V 3.1.1
 TRADING AND DEMAT ACCOUNT RELATED DETAILS
SECTION A PRIMARY BANKING ACCOUNT (DIVIDEND BANK DETAILS)

BANK NAME UNION BANK OF INDIA BRANCH NAME DHANAUT BRANCH PATNA
BRANCH ADDRESS
CITY/TOWN/VILLAGE 400001 STATE
PIN CODE
PATNA COUNTRY India
ACCOUNT NUMBER 687102010006343

MICR NUMBER 3 9 0 0 2 6 0 0 2 IFSC CODE UBIN0572675

ACCOUNT TYPE CURRENT SAVINGS NRI / NRE / NRO OTHERS (Please Specify)

SECTION B PRIMARY DEPOSITORY ACCOUNT (OPTIONAL)

DEPOSITORY PARTICIPANT NAME DP TYPE (NSDL/CDSL) DEPOSITORY PARTICIPANT ID

BENEFICIARY NAME BENEFICIARY ID (BO ID)

SECTION C TRADING PREFERENCES SECURITIES

Please sign in the relevant boxes where you wish to trade. The segment not chosen should be struck off by the client. If, in future, the client wants to trade on any
new segment / new exchange, separate authorization / letter should be taken from the client by the stock broker.

BSE CASH SEGMENT NSE CASH SEGMENT BSE F&O SEGMENT

X X X
CLIENT’S SIGNATURE [4A] CLIENT’S SIGNATURE [4B] CLIENT’S SIGNATURE [4C]

NSE F&O SEGMENT BSE CDS SEGMENT NSE CDS SEGMENT

X X X
CLIENT’S SIGNATURE [4D] CLIENT’S SIGNATURE [4E] CLIENT’S SIGNATURE [4F]

SECTION D TRADING PREFERENCES COMMODITIES

MCX COM SEGMENT NSE COM SEGMENT

X X DATE (DD/MM/YYYY)
CLIENT’S SIGNATURE [4G] CLIENT’S SIGNATURE [4H] 0 3 1 2 2 0 2 4

OTHER DETAILS

GROSS ANNUAL INCOME DETAILS (Income Range per annum) NET WORTH AS ON DATE (NOT OLDER THAN 1 YEAR)
UP TO RS. 1 LAC RS. 1 LAC - RS. 5 LAC RS. 5 LAC - RS. 10 LAC VALUE IN Rs.
RS. 10 LAC - RS. 25 LAC MORE THAN RS. 25 LAC DATE (DD/MM/YYYY)

FOR NON INDIVIDUALS: 25 LAC - 1 CRORE OVER 1 CRORE

Occupation Type* S-Service ( Private Sector Public Sector Government Sector )

✔ O-Others Professional Self Employed Retired Housewife ✔ Student )
B-Business X- Not Categorised Agriculturist

AFFILIATIONS: POLITICALLY EXPOSED PERSON (PEP) RELATED TO A POLITICALLY EXPOSED PERSON (RPEP)

ANY OTHER INFORMATION:

PAGE 3
V 3.1.0
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 2024-12-03T00:06:16.537+05:30 Download date 2024-12-03T00:06:16.537+05:30

Masked Aadhaar
Number xxxxxxxx6158
Name Amit Prakash

Date of birth 07-09-1997

Gender MALE

c/o, s/o, S/O: Tej Narayan Prakash

55, IAS Colony Bailey Road Beside Maruti Showroom
Danapur Cantt Dinapur-Cum-Khagaul Danapur Patna,
801503, Bihar

Address

Beside Maruti Showroom

Landmark Locality

City/District Patna

PIN Code 801503 State Bihar

Digitally signed e-Aadhaar XML
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I wish to register the mentioned signature as authorized signature for all activities and correspondence with RKSV/Upstox

Signature as per our records