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NSDL - Dematerialisation Request Form

ICICI DRF

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Alpesh Patel
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386 views

NSDL - Dematerialisation Request Form

ICICI DRF

Uploaded by

Alpesh Patel
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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ICICI Bank Limited, CPC-Demat Services, Ground Floor, B-Wing, Autumn Estate, Chandivali Farm Road, Opp.

Mhada Colony, Chandivali, Andheri (East), Mumbai-400072.


(Important Note: Please do not send requests directly to this address. Kindly route all your requests through the nearest ICICI Bank Demat Servicing Branches)

Dematerialisation Request Form (NSDL)


For ICICI Bank Only
Date of receipt D D M M Y Y Y Y DRN DRF

INDOC No. Sequence No. CPO SR No.


To be filled in by holder(s)
I/We hereby request ICICI Bank to dematerialise the enclosed certificates into my/our demat account as per details given below:
Date D D M M Y Y Y Y DP ID I N Client ID

*Mobile No. *Email

Account Holder Name First/Sole Holder


Second Holder
Third Holder
Quantity of securities to be dematerialised (in figures) (in words)
Name Of the securities Face value Rs.
ISIN (To be filled in by DP) I N

Details of securities Type of securities Equity Others


Folio No. Cretificate No. Quantity (in figures) From Distinctive No. To Distinctive No.

In case the space is insufficient, please attach an annexure containing the details of the certificate in the same format.
Submit different DRF for securify certificates of the same company having different ISINs. Bonds and Debentures of different series issued by the
same company generally have different ISINs. Verify them from the Branch if in doubt.
Please use separate form for free securities and locked-in securities.

Total number of certificates surrendered


Please tick if the dematerialisation request is for locked shares. Lock-in release date D D M M Y Y Y Y
Lock-in reason

Declaration: I/We hereby declare that the above-mentioned securities are registered in my/our name. The original certificate(s) is/are hereby surrendered
by me/us for dematerialisation. I/We also hereby declare that the securities submitted by me/us for dematerialisation are free from any lien or charge or
encumbrance and represents the bonafide securities of the company to the best of my/our knowledge and belief.

Holder's signature(s) (If the signature registered with the Company/Registrar is different from the specimen signature given to the DP, please affix both
signatures on the DRF)
Name Signature with DP

First/Sole Holder

Second Holder

Third Holder -

For ICICI Bank use only


Participant Authorisation
Received the above mentioned securities for dematerialisation. The application form has been verified with the certificates surrendered for dematerialisa
and certify that the application form is in accordance with the details mentioned in the enclosed certificates. It is also certified that the holders hold
beneficiary accounts with us in the same name.

Name of the DP Official

Signature of the DP Official


Participant’s Stamp & Date
For Branch Use Only

I confirm that the account is active, applicant(s) signed in mypresence, all relevant details are matching in our Bank records
and verified by me.

Name & Employee ID:

Signature of the Branch Official:

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