(on letter-head of the AP)

……../ ……../ ……..

To
Prabhudas Lilladher Pvt. Ltd.
3rd Floor, Sadhana House,
570, P.B. Marg, Worli,
Mumbai – 400018, Maharashtra.

Subject: Self-declaration by Authorized Person (‘AP’) of Prabhudas Lilladher Pvt. Ltd. (‘PLPL’) in connection
with inspection carried out by PLPL.

AP Name & AP Code Name …………………………………………………………………………………………/ Code …………………………

NSE Registration No. ……………………………………………………………………………

BSE Registration No. ……………………………………………………………………………

MCX Registration No. ……………………………………………………………………………

Dear Sir,

I, ………………………………………………………………………………………., authorized signatory of the aforesaid AP do hereby

confirm and declare on behalf of the AP the following;
1. There is no movement of funds/securities between us and the clients.
2. There are no cash dealings between us and the clients.
3. We have not dealt with any other trading member/AP on behalf of the clients/self on the same Stock
Exchange.
4. We have not dealt with any unregistered intermediary on behalf of the clients/self.
5. We are not involved in accepting deposits from the public and giving assured returns.
6. We have not solicited any business by issuing any advertisements in the newspaper, pamphlets, journals,
magazine etc.
7. We are not in possession of any blank cheques/ DIS, whether signed or unsigned, belonging to any client.
8. We are conducting the In-person Verification of clients in accordance with the guidelines prescribed by the
Regulators/Exchanges from time to time.
9. Terminals allocated to us are being operated by approved and certified users.
10. Pre Trade order placement system is there and there are no unauthorized trades in client accounts.

In addition to the aforesaid we do hereby confirm that should we be found in violation of any of the aforesaid
points by the Regulators/Exchanges, we shall be liable to any action taken by PLPL including but not limited to
bearing the penalty levied by the Regulators/Exchanges in entirety.

For ……………………………………………….(AP Name)

……………………………………….(Signature)