Change of Status Form

Date:

Mailing Address: Forever Plaza, 74, Hill Road, Opp. St. Stanislaus High School, Bandra (W), Mumbai 400 050.

I, bearing FBO ID#* would like to add/change/delete the following details in the system:
Please tick the applicable boxes of the information that you would like to change:

1. NAME CORRECTION:

Previous FBO Name:* Last First Middle

(as per system)
New FBO Name: Last First Middle

2. ADDRESS CORRECTION: (Please submit copy of Aadhar/Passport/Election Card/Bank Statement/ Driving License/Voter ID/Light Bill or Electricity Bill showing address page.)
Previous Address: (as per system)

New Address:

` 3. CONTACT INFORMATION CORRECTION: (Please note that either the Mobile or Alternative Contact can be deleted and not both.)
Previous Information: (as per system) Delete Delete
Mobile:* Alternative Contact No:*

Email Address:* Delete

New Information:

Mobile:* Alternative Contact No:*

Email Address*:

4. PERMANENT ACCOUNT NUMBER (PAN) CORRECTION: (Please submit copy of PAN Card. PAN has to be of the applicant in who’s name the FBO ID is in.)

PAN Number:*

5. SPOUSE INFORMATION CORRECTION: (Applicable only for the applications which contains Primary and Secondary name)

Spouse Name: Last First Middle

Make Primary Applicant Delete Spouse Correct Name SPOUSE SIGNATURE:

6. ANY SPECIAL REQUESTS:

I understand that requesting the above mentioned changes me/or my spouse will adhere to the rules, regulations and current policies set forth by the Company.

DETAILS OF PERSON SUBMITTING THIS FORM: FBO SIGNATURE:

Name:

FBO ID#: SIGNATURE:

* Marked fields are mandatory

Quick Tip: To have your information updated faster, submit a scanned copy of this form with signatures via email to flpcare@flpindia.net
Ver 10/29/20