cg';"rL – !@ Annex - 12 kmf=g+=M ! Form No.

: 1

-ljlgod @) ;“u ;DalGwt_ (Pursant to Byelaw 20)

xfn;fn}
k|fs[lts JolQmsf] lxtu|fxL vftf vf]Ng] lgj]bgsf] 9f“rf lvlrPsf] kmf]6f]
Format of Account Opening Form for Individual Beneficial Owner Recent
Photo
(KYC) (BO) (Both)
sfof{no k|of]hgsf nflu dfq For Official Use Only
cfj]bg gDa/ M ;+s]t gDa/ M ldlt M
Application No.: Symbol No.: Date :
u|fxs gDa/ M
Customer No.:

lxtu|fxLsf] vftf gDa/M (Demate)

Beneficial Owner Account No.:

lxtu|fxL vftf vf]lnPsf] ;+:yfsf] gfd

tn pNn]lvt ;Dk"0f{ ljj/0f /fd|f];+u eg'{ kg]{5 . cfkm";+u ;/f]sf/ gePsf] ljj/0f pNn]v ug]{ sf]7fdf t];|f]{ wsf{ tflglbg' xf]nf .
Please complete all details and strike out the non-applicable fields/boxes.
lgIf]k ;b:osf] gfd M cfo{tf/f OGe]i6d]G6 P08 ;]So'l/l6h k|f= ln=
-zfvf / Branch)
vftfsf] lsl;d M JolQmut u}/ cfjf;Lo g]kfnL ljb]zL
Types of Account : Individual Non Resident Nepalese Foreigner

lxtu|fxLsf] ljj/0f
gfd
Name of Beneficial Owner
hGd ldlt la=;+= O{= ;+=
Date of Birth B. S. A. D.
ln· k'?if dlxnf ljjflxt cljjflxt /fli6«otf g]kfnL cGo
Gender Male Female Married Un Married Nationality Nepali Other
gful/stf gDa/ hf/L lhNnf hf/L ldlt
Citizenship No. Issue District Issue Date
/fxbfgL gDa/ hf/L 7fp“ hf/L ldlt Dofb ;lsg] ldlt
Passport No. Place of Issue Issue Date Expiry Date
kl/rokqsf] lsl;d kl/rokq g+= hf/L ug]{ lgsfo hf/L ldlt
Types of Identity Card Identification No. Issuance Authority Issue Date

kqfrf/ ug] { 7]u fgf M

Correspondence Address:
/fi6« M k|b]z M lhNnf M
Province : District : uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Country : Rural Municipality/Municipality/
6f]n M j8f g+=M Sub Metropolitan city/
Tole : Ward No.: Metropolitan city

6]lnkmf]g g+=M df]afOn g+=M

Telephone No.: Mobile No.:
Kofg g+=M O{d]n M
Pan No.: E-mail ID :
:yfoL 7] u fgf M
Permanent Address:
k|b]z M lhNnf M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
Province : District : Sub Metropolitan city/Metropolitan city
6f]n M j8f g+=M Ans g+=M
Tole : Ward No.: Block No.:
6]lnkmf]g g+=M df]afOn g+=M
Telephone No.: Mobile No.:
km\ofS; g+=M O{d]n M
Fax No.: E-mail ID :
glhssf] NofG8dfs{ M
Nearest Landmark :
Psf3/ kl/jf/sf ;b:ox?sf] ljj/0f Details of Family Members
a'afsf] gfd
Father's Name
xh'/ a'afsf] gfd
Grand Father's Name
cfdfsf] gfd
Mother's Name
klt÷kTgLsf] gfd
Spouse's Name
5f]/fsf] gfd
Son's Name
cljjflxt 5f]/Lsf] gfd
Unmarried Daughter's Name
a'xf/Lsf] gfd
Daughter's in Law's Name
;;'/fsf] gfd
Father's in Law's Name
;f;'sf] gfd
Mother's in Law's Name

k]zfut ljj/0f Details of Occupation

k]zf M ;]jfM ;/sf/L ;fdflhs÷lghL If]q Pg=hL=cf]=÷cfO{ =Pg=hL=cf]= sfg"gL lj1 ljBfyL{
Occupation : Service: Goverment Public/Private Sector NGO/INGO Legal Export Student
ljz]if1 Jofkf/L ;]jf lgj[Q u[lx0fL cGo
Expert Businessperson Retired House Wife Others
Jofkf/sf] k|sf/ M pTkfbg ;]jfd'vL
Types of Business : Manufacturing Service Oriented
sDkgL÷;+:yfsf] gfd M
Com./Organization's Name :
7]ufgf kb
Address Designation
cfly{s ljj/0f M cfosf] ;Ldf -jflif{s ljj/0f / Income Limit (Annual Details)
Financial Details : ?= !,)),))) ;Dd ?= !,)),))! b]lv ?= %,)),))) ;Dd
Upto Rs. 1,00,000 From Rs. 1,00,001 to Rs. 5,00,000
?= %,)),))! b]lv ?= !),)),))) ;Dd ?= !),)),))) eGbf dfly
From Rs. 5,00,001 to Rs. 10,00,000 Above Rs. 10,00,000

lgIf]k ;b:on] lxuu|fxLsf] vftfdf ePsf] 36a9 :jrflnt ?kdf u/fpg]÷gu/fpg] . u/fpg] gu/fpg]
Standing Instruction for the automatic transactions Yes No
vftfsf] ljj/0f k|fKt ug]{ b}lgs ;fKtflxs kflIfs dfl;s
Account Statement Daily Weekly 15 days Monthly

;+/Ifssf] ljj/0f -gfafnssf] xsdf dfq_ Guardian's Details (In case of Minor only)
gfd÷y/ M
Name/Surname :
lgj]bs;+usf] ;DaGw M
Relationship with applicant :
kqfrf/ 7]ufgf M
Correspondence Address :
/fi6« M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
Country : Sub Metropolitan city/Metropolitan city
lhNnf M j8f g+=M
District : Ward No.:
6]lnkmf]g g+=M df]afOn g+=M
Telephone No.: Mobile No.:
:yfoL n]vf g+=M O{d]n M
PAN No.: E-mail ID :
-gfafnssf] xsdf ;+/Ifs tyf gfafns b'a}sf] kmf]6f] ;+n Ug ug'{ kg]{5_ (In case of minor, guardian and minor's photos are required to submit.)

cf}+7f 5fk Thumb Print

;+/Ifssf] gfd M
bfof“ afof“
Right Left
Guardian's Name :
kmf]6f]
x:tfIf/ M
Signature :

u}/ cfjfl;o g]kfnLsf nflu For Non Resident Nepalese

j}b]lzs 7]ufgf M
Foreign Address :
;x/ M /fHo M
City : State :
b]z M u}/cfjfl;o sf]8 g+=M
Contry : NRN Code No.:

cf}+7f 5fk Thumb Print

lgj]bssf] gfd M
bfof“ afof“
Right Left
Applicant's Name :

x:tfIf/ M
Signature :

a}+s vftfsf] ljj/0f Bank Account Details

a}+s vftfsf] lsl;d M art vftf rNtL vftf
Types of Bank Account : Saving Account Current Account
a}+s vftf gDa/ M
Bank Account Number :
tkfO{sf] a}+s vftf ePsf] a}+ssf] gfd M
Name of Bank :
a}+s zfvfsf] gfd M
Name of Branch :

OR5fOPsf] JolQm ;DaGwL ljj/0f Nominee's Details

d]/f] d[To' ePsf] cj:yf jf d}n] g;s]sf] cj:yfdf b]xfosf] JolQmn] d]/f] gfddf ePsf] ;Dk"0f{ lwtf]kqsf] xsbfjL ug{ kfpg] 5 .
In the event of my death or incapacity, the following named nominee shall be entitled to the balance of my demat account .

xsbfjL ug]{sf] gfd M lgj]bs;+usf] ;DaGw M

Name of Nominee : Relationship :
gful/stf÷/fxbfgL gDa/ M hf/L 7fp“ M pd]/ M
Citizenship/Passport No.: Place of issue : Age :
kqfrf/ 7]ufgf M
Correspondence Address :
/fi6« M c+rn M
Country : Zone :
lhNnf M 6]lnkmf]g g+=M
District : Telephone No.:
km\ofS; g+=M df]afOn g+=M
Fax No.: Mobile No.:
:yfoL n]vf g+=M O{d]n M
PAN No.: E-mail ID :

cf}+7f 5fk Thumb Print xsbfaL ug]{ JolQmsf] gfd M

bfof“ afof“
Right Left Name of Nominee :

x:tfIf/ M
Signature :
 Site Map of the Account Holder's Residence

3/ /x]s f] :yfgsf] gSzf

Location Map

From main Road Street.............. the distance of the Residence is.......... meters (approximately).

sf/f]af/ ;DalGw yk ljj/0f (Transaction related additional information)

!= cfDbfgLsf] >f]t 3 nufpg' xf]; M Joj;foLs cfDbfgL tna÷kfl/>lds nufgL k|ltkmn 3/ ef8f lwtf]kq sf/f]jf/
ljk|]if0f k}t[s Aofh cGo pNn]v ug'{xf]; ========================================================================================
@= cGo lwtf]kq bnfn sDkgLdf sf/f]jf/ ug]{ u/]sf] M 5}g 5
5 eg] sDkgLsf] gfd M ================================================================================== u|fxs sf]8M =======================================
#= tkfO{ shf{ ;"rgf s]Gb| -;'/If0f lgud_ ln= sf] sfnf];'rLdf /xg' ePsf] 5 < 5}g 5
;DklQ z'l4s/0f tyf cftÍsf/L s[ofsnfkdf ljlQo lgjf/0f ;DaGwL yk ljj/0fM
!= s] tkfO{ /fhg}lts jf pRr kb:y JolQm x'g'x'G5 < xf] xf]O{g
@= s] tkfO{ /fhg}lts jf pRr kb:y JolQm ;+u ;DalGw x'g'x'G5 < 5' 5} g
;DalGwt /fhg}lts÷pRr kb:y JolQmsf] gfd tkfO{;+usf] ;DaGw
==================================================================================================================== ===========================================
#= s] tkfO{sf] lxtflwsf/L JolQm 5 < 5} g 5
lxtflwsf/L JolQmsf] gfd tkfO{;+usf] ;DaGw
==================================================================================================================== ===========================================
$= s] tkfO{ ljutdf s'g} ;Da4 s;'/df bf]ifL k|dfl0ft x'g' ePsf] 5 < 5} g 5
;DklQ z'l4s/0f -dgL nfp08l/·_ lgjf/0f P]g, @)^$ sf] bkmf @ sf] v08 -z_ adf]lhdsf s;'/x?
5 eg] s[kof pNn]v ug'{xf]; ======================================================================================================================================
axfndf a:g]sf] xsdf
3/ wgLsf] gfd M =================================================================================================== 6]lnkmf]g g+= ====================================
df]afO{n g+= =================================== lhNnf M=========================== dgkf÷pkdgkf÷gkf÷uflj;M===================================================
j8f g+=M===============6f]n M========================================================================================== 3/ g+ =M==========================================
lwtf]kq sf/f]jf/sf] ;DaGwdf tklzn adf]lhdsf] :j3f]if0ff ub{5' .
!= d÷xfdLn] lwtf]kq vl/bsf nflu k|of]u ug]{ /sd ;DkQL z'l4s/0f %= d÷xfdL shf{ ;"rgf s]Gb|sf] sfnf] ;'rLdf /x]sf] 5'÷5}g .
;DaGwL k|rlnt sfg'g ljkl/t cfh{g u/]sf] x'g] 5}g . ^= ;DklQ z'l4s/0f -dgL nfp08l/·_ lgjf/0f P]g, @)^$ / o; cGt/ut
@= lwtf]kqdf ul/Psf] nufgLdf lglxt hf]lvdsf] ;DaGwdf hfgsf/ 5' . hf/L ePsf lgodfjln tyf lgb]{zg cfbLaf6 dfu eP cg';f/sf ;'rgf,
#= d÷xfdLn] vl/b u/]sf lwtf]kqx? jfktsf] e'QmfgL lng] lbg] sfo{ tf]lsPsf] ljj/0f tyf sfuhftx? sDkgLnfO{ pknAw u/fpg] 5'÷5f}+ .
;do leq ug]{ 5' . &= sDkgLnfO{ ug'{ kg]{ e'QmfgL gul/ af+sL /fv]sf] sf/0faf6 d]/f]÷xfd|f]
$= d÷xfdLn] lwtf]kq ;DaGwL tyf cGo k|rlnt lgod sfg"gx?sf] kfngf sf/f]jf/ cGo lwtf]kq bnfn sDkgLx?df ;d]t lgnDag ug{ kqfrf/ jf
ug]{5' . kl/kq ug{ d]/f]÷xfd|f] d~h'/L 5 .
dfly pNn]lvt ljj/0f ;To tYo /x]sf] / ;f] ljj/0fdf s'g} km/s k/] sfg"g adf]lhd ;x'“nf, a'emfp“nf . I/We hereby acknowledge that the above
disclosed details are true. I further hereby consent to bear any legal actions in case any false disclosure of information related to me/us.
cf}+7f 5fk Thumb Print lgj]bssf] gfd M Applicant's Name :
bfof“/Right afof“/Left
x:tfIf/ M
Signature :
-x:tfIf/ ubf{ sfnf] d;Lsf] k|of]u ug'{ kg]{5_
(Please use Black ink.)

l;kmfl/; stf{sf] gfdM ==================================== kmf]g g+=M ====================================

sfof{no k|of]hgsf] nflu (For Official Use)
?h' ug]{M k|dfl0ft ug]{ M
gfd, y/ M gfd, y/ M
kb M kb M
x:tfIf/ M x:tfIf/ M
ldlt M sfof{nosf] gfd tyf 5fk ldlt M
==============================
k|lji6L ug]{sf] x:tfIf/