Intermediary Registration Form

KYC REGISTRATION AGENCY
INTERMEDIARY REGISTRATION FORM
We hereby request you to register us as an Intermediary with NDML KRA pursuant to the SEBI
KYC (Know Your Client) Registration Agency Regulations, 2011.
1
3
Name of the
Intermediary
Registration No. (allotted by Registrar
of Companies in case of a Company)
Date of incorporation (DD/MM/YYYY)
4
SEBI Registration Number
5
DP ID (In case of a Depository
Participant with NSDL)
PAN of the Intermediary
2
6
7
Registered
Office Address
PIN Code
City / Town
State
Country
Telephone No.
8
Fax No.
Correspondence
Address
City / Town
9
PIN Code
State
Country
Telephone No.
Compliance Officer Details
Name
Designation
Email ID
Telephone No.
Mobile Number
Fax No.
Fax Number
Page 1
10
Administrator User Details
Name
Designation
Email ID
Telephone No.
Mobile Number
Digital Signature details
Fax No
Name of Certifying Authority
Certificate Serial No
Declaration
The rules and regulations pertaining to Intermediary as issued by SEBI under KYC (Know Your
Client) Registration Agency Regulations, 2011 and its guidelines thereof, which are in force, have
been read and understood by us and we agree to abide by and to be bound by the same. We
declare that the information given by us is true and correct. We further agree that if any
information given by us is false or misleading or any material fact is suppressed, it will render our
KRA Intermediary registration liable for termination and appropriate action.
Sr.No
Name of Authorised Signatory
Place :
Signature
Stamp of the
Intermediary
Date:
Instructions:
1) Submit duly filled and signed form at : NDML KRA, 4th Floor, A wing, Trade World, Kamala
Mills Compound, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
2) Enclose the following documents along with the Intermediary Registration Form:
a) Copy of SEBI Registration Certificate
b) Duly Signed Terms and Conditions
c) Duly filled User Creation Form
Page 2