216121 21312156856269

MANDATORY
Kotak Securities Ltd.

CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual
Please fill the form in English and in BLOCK Letters. | Please read section wise detailed guidelines / instructions mentioned at the beginning.
1. PERSONAL DETAILS (Please refer instruction A) KRA I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER
Prefix
Name*(Same as ID proof) PROSENJIT GHOSAL First Name Middle Name Last Name

Maiden Name (if any*) Prefix First Name Middle Name Last Name

Father/Spouse Name* Prefix GHOSAL

BISHWANATH First Name Middle Name Last Name
Prefix
Mother Name* KRISHNA GHOSAL First Name Middle Name Last Name
Nationality* Indian
AUSPG9608E
PAN Card PHOTOGRAPH
NOT APPLICABLE
Date of Birth* D D / M
16/02/1992 M / Y Y Y Y FOR UIDAI CLIENTS

Gender* c M-Male c F-Female c T- Transgender

Marital Status* c Married c Unmarried c Others
Residential Status* c Resident Individual c Foreign National
Occupation Type* c S-Service ( c Private Sector c Public Sector c Government Sector) c 2
12
c O-Others ( c Professional c Self Employed c Retired c Housewife c Student)
c B-Business c Agriculturist c Forex Dealer c Others______Please Specify_____
I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital
2. PROOF OF IDENTITY AND ADDRESS (Please refer instruction B) KYC process needs to be submitted (anyone of the following OVDs)

c
KRA I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER
A-Passport No. Passport Expiry Date D D / M M / Y Y Y Y
c B-Voter ID Card
c C-Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y
c D-NREGA Job Card
c E-National Population Register Letter
c F-Proof of Possession of Aadhaar/ VID (Virtual ID) 7 1 3 7 /
c E-KYC Authentication
c Offline verification of Aadhaar
Address: Line 1* _______________________________________________________________________________________________________
S/O BISHWANATH GHOSAL,183,MAIN ROAD,NEAR S.S HIGH, SCHOOL,PATRATU,RAMGARH,JHARKHAND,829119,
Line 2 ______________________________________________________________________________________________________________
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
City /Town /Village*____________________________________________________________________
RAMGARH District*__________________________
Pin Code*_______________________________
829119 State/U.T*____________________________________
Jharkhand Country*_________________________
India

I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be
3. CURRENT ADDRESS DETAILS (Please refer instruction B) submitted (anyone of the following OVDs)

KRA
c
I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER
A-Passport No.
c Same as above mentioned address (In such cases address details as below need not be provided)

Passport Expiry Date D D / M M / Y Y Y Y

c B-Voter ID Card
c C-Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y
c D-NREGA Job Card
c E-National Population Register Letter
c F-Proof of Possession of Aadhaar/ VID (Virtual ID) 7 1 3 7 /
c E-KYC Authentication
c Offline verification of Aadhaar
c Deemed Proof of Address - Document Type ________________________________________________________________________________
Address: Line 1* _______________________________________________________________________________________________________
S/O BISHWANATH GHOSAL,183,MAIN ROAD,NEAR S.S HIGH, SCHOOL,PATRATU,RAMGARH,JHARKHAND,829119,
Line 2 ______________________________________________________________________________________________________________
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
City /Town /Village* ____________________________________________________________________
RAMGARH District* _________________________
Ver 13/20-21/270721

Pin Code*_______________________________ State/U.T*____________________________________

829119 Jharkhand Country*_________________________
India

2
 216121 21312156856269
MANDATORY
4. CONTACT DETAILS (Please refer instruction C) (All communications will be sent on provided Mobile no. / Email-ID)
KRA I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER This section is “Not Applicable” for customers who are KRA complied or have
provided consent for authenticating with UIDAI system.

Tel.(Res.) 9 1 - Mobile 9 1 - 8863097465

Tel.(Off.) 9 1 - Fax 9 1 -
E-mail ID. PRO1775@GMAIL.COM

5. DETAILS OF RELATED PERSON KRA I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER I
In case if you wish to appoint “Authorised Representative” to your account please get in touch with your respective Relationship
Manager

6. REMARKS (If any) KRA I AADHAR I DIGI LOCKER I NON KRA / NON AADHAR / NON DIGI LOCKER I

7. APPLICANT DECLARATION
l
KRA AADHAR I
DIGI LOCKER I I
NON KRA / NON AADHAR / NON DIGI LOCKER
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to
I
inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading
or misrepresenting, I am aware that I may be held liable for it.
l I/We hereby consent to receiving information from KRA / Central KYC Registry through SMS/Email on the above registered
number/Email address.
l I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be validated against Aadhaar details. I/We hereby
consent to sharing my/our masked Aadhaar card with readable QR code or my Aadhaar XML/Digilocker XML file, along with
passcode and as applicable, with KRA and other Intermediaries with whom I have a business relationship for KYC purposes only.
Signature of Account Holder
RAMGARH
Place __________________________ c 3
13

Date __________________________
19/12/2023

For Office Use Only

Application Type* c New c Update
KYC Number (Mandatory for KYC update request)
(To be filled by financial institution)

Account Type* c Normal c Minor c Aadhaar OTP Based E-KYC (in non-face to face mode)
Document Received c Certified Copies c E-KYC data received from UIDAI
c Data received from Offline verification c Digital KYC Process
c Equivalent e-document c Video Based KYC

Check list to be verified by acquiring sales staff

Details Documents verified with original / Client Interviewed By / In-Person Verification done by

Name of the Employee / Authorised person

Employee Code / SEBI Reg. No. / AP Reg. No.
Name & Address of Branch/Franchisee/
Service Center
Designation of the Employee
Date
Place of verification
Signature
Name of Institution Code of Institution Stamp
of
Kotak Securities Ltd. NSE Code - 08081 BSE Code - 673 MSE Code - 1024 Kotak Securities Ltd.
Institution
MCX - 56285 NCDEX - 1262
 PAN Card

This document is digitally signed. Please refer to Annexure A for digital signature.

48
 Signature

This document is digitally signed. Please refer to Annexure A for digital signature.

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