216121 21312157068054

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) KOMAL First Name
KALUBHAI PARMAR Middle Name Last Name

Maiden Name (if any*) Prefix First Name Middle Name Last Name
Prefix
Father/Spouse Name* Kalabhai First Name
MITHABHAI PARMAR Middle Name Last Name

Mother Name* Prefix

MADHUBEN KALABHAIFirst Name
PARMAR Middle Name Last Name
Nationality* Indian

PAN Card GIQPP7579K PHOTOGRAPH

NOT APPLICABLE
Date of Birth* D D / M M/ Y Y Y Y
22/06/2001 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) /
c E-KYC Authentication
c Offline verification of Aadhaar 9631
Address: Line 1* _______________________________________________________________________________________________________
172 Gajanand Park Society, Bhari Mata Road Surat,
Line 2 ______________________________________________________________________________________________________________
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
City /Town /Village*____________________________________________________________________
Surat City District*__________________________
Surat

Pin Code*_______________________________
395004 State/U.T*____________________________________
Gujarat 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) /
c E-KYC Authentication
c Offline verification of Aadhaar 9631
c Deemed Proof of Address - Document Type ________________________________________________________________________________
Address: Line 1* _______________________________________________________________________________________________________
172 Gajanand Park Society, Bhari Mata Road Surat,
Line 2 ______________________________________________________________________________________________________________
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
City /Town /Village* ____________________________________________________________________
Surat City District* _________________________
Surat
Ver 13/20-21/270721

Pin Code*_______________________________ State/U.T*____________________________________ Country*_________________________

395004 Gujarat India

2
 216121 21312157068054
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 S T D - Mobile 9 1 - 7802824249

Tel.(Off.) 9 1 S T D - Fax 9 1 S T D -
E-mail ID. PARMARKOMALL2203@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 KRA AADHAR DIGI LOCKER NON KRA / NON AADHAR / NON DIGI LOCKER
I I I
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.
I/We hereby consent to receiving information from KRA / Central KYC Registry through SMS/Email on the above
registered number/Email address.
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.
I/We hereby give my/our consent to Kotak Securities Limited (KSL) to access and/or download my/our CKYC record from the
Central KYC Records Registry (CKYCRR) for the purpose of account opening or for carrying out any modification of details in my/
our account. I/We also agree and confirm to share any and all such records with all Regulators including but not limited to KRAs
(Know Your Client Registration Agency) for the purpose of validation of KYC by the KRAs, and shall also be stored by KSL for
record purpose.

Place __________________________
Surat City Signature of Account Holder
c 3
Date __________________________
31/01/2024 13

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
Data received from Offline verification
c 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 Institution
Kotak Securities Ltd.
MCX - 56285 NCDEX - 1262
 PAN VERIFICATION RECORD
Permanent Account Number

GIQPP7579K
Name KOMAL KALUBHAI PARMAR
Gender FEMALE
DOB 22/06/2001
Verified On 24/01/2024 09:12:54

Digitally Signed On:

24/01/2024 09:12:54 IST

Note:

1. This PAN data is verified by DigiLocker (https://digilocker.gov.in) as per data provided

by the issuing authority, Income Tax Department, Govt. of India.
2. This digitally signed verification document is valid as per the IT Act 2000 when used
electronically.

Powered by TCPDF (www.tcpdf.org)

 DIGILOCKER Verified E- Aadhaar

This is the document generated by Kotak Securities with resident ’s (client 's) express consent and on the
basis of E-Aadhaar generated from Digilocker verified Aadhaar XML shared by the resident (client ) with
Kotak Securities for the purpose of opening Trading and /-or Demat account . This document will be used as
an ID and /-or Address proof for record purposes.

Document Type E-Aadhaar generated from Digilocker verified Aadhaar XML

Generated Date 2024-01-24T09:09:58.956+05:30 Downloaded Date 2024-01-24T09:09:58.956+05:30

Masked Aadhaar xxxxxxxx9631

Name PARMAR KOMAL KALABHAI
Date of Birth 22-06-2001
Gender FEMALE
C/o , S/o
172 GAJANAND PARK SOCIETY,
BHARI MATA ROAD, SURAT,
Address SURAT CITY, SURAT, GUJARAT,
395004, INDIA

SURAT
Landmark Locality

City / District SURAT

Pin code 395004 State GUJARAT

 Signature

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

49