FORM NO. INC-3 [Pursuant to section 3(1) of the Companies ‘Act, 2013 and pursuant to Rule 4(2), (3), (A), (5) & (6) of the Companies (ncorperation) Rules, 2014) Formlanguage — @ English Q Hind Refer the instruction kit for filing the form. One Person Company - Nominee Consent Form 1. (@) “SRN of RUA (In case of new company) or [esrozoe16 Prectil Corporate identity Number (CIN) ofthe company (In case of existing Company) (©) Global location number (GLN) 2. (@) Name ofthe One Person Company. [KAPIL K VENTURES [OPO) PRIVATE LIMITED aan] 3. “Consent | RAVITA KHANDALE hereby give my consent to become the member ot [KAPIL K VENTURES (OPO) PRI in the event of death of [kaPIL KHANDALE subscriberimember of the company or his Incapacity to contract. 4, Pariculars of tie nominee Director Identification number(DIN) PreFil |"Income-tax permanent account number (PAN) [SCRPKIG63A Verity Detalls FirstName KAVITA Middle Name ‘Sumame —_[KHANDALE Family Name "@FatnersName CQ) Moers Name) Spouse's rame [PNYANOBA PANDURANG KHANDALE Gender © Male @ Female OTransgender Nationality fay ‘Date of Bith foqroar1093 "Place of Bith (District and Stato) [PUNE Educational Qualification [Graduation/BachelorEquivalent * Occupation ype © Set-ompoyea © Professional Homemaker «© Student. © Serviceman ‘Atea of occupation [LAWYER Page 1 of 3Pormanent Residential Address “Line | [an NO.38/2, 207, SAWARKAR CHOWK, Line | [KHANDALE BUILDING, 1ST FLOOR, DHANKWADI, “cty [PUNE “State/Union Territory [yfaharashira-MH “in code far 1043 1s0 County Coe fpy Country [inDia *Phone (with STDNSD Code) fao9 _ porvers700 ‘Mobile (with country code) = Fax email id (kapikrandales700@omall com “Whether present address is same as the permanent address. © @ Yes © No Present Address “Line | [SN NO36/2, 207, SAWARKAR CHOWK Une | [KHANDALE BUILDING, 1ST FLOOR, OHANKWADI, “Cty PUNE *StatefUnion Teroty [fanarashaMH “Pin code [arioas "ISO Country Code [IN Country fInDia “Phone win STOMSD Code) feap ~ bonerar00 Mobile (with country code) = Fax email id “Duration of say atthe presert actress ps year) month(s) I duration of stay at present accress is less than one year then address of previous residence “Proof ofidentty [wadhar Number *Residertial Proof [Bank Statement Declaration | do solemnly deciare that | am an Indian ctzen and resident in India and | have not been convicted of any offence in connection with the promotion, formation or management of any company or LLP and have not been found gulty of any fraud or misfeasance or of ‘any breach of duty to any company under this Actor any previous company law or LLP Actin te last ve years, | futher dectare that | am not a nominee in any other One Person Company and I shall comply withthe eligibility criteria specified in Rule 3(3) within the Prescribed period. | understand thatthe person nominating me may withdraw my nomination witnout my consent ‘To be physically signed by Nominee ‘Date [fe.06-2018 “piace [PUNE Page 2 of 3Enclosures 1. Copy of PAN Card 2. Proof ot ientty 3. Residential Proof Modify (Check Form Note : Attention is crn to provisions of section 75) and 7(6) which intet-alia, provides that funishing of any false or Incorrect parculars of any information or suppression of any material information shall attract punishment for fraud under section 447. Attention is also drawn to provisions of section 448 and 449 which provide for punishment for false statement ‘and punishment or fase evidence respectively. This is a non e-Form. User is required to fill the form electronically and duly signed copy should be attached with ‘e-Form INC-2, INC-4 or INC-6, 28 the case may be. Page 3 of 3