12 ‘THE GAZETTE OF INDIA : EXTRAORDINARY [Parr sec. 30] Leotard Foun language Return of appointment of managerial personnel [Pursuant to Section 196 read with Section 197 and @ ace Hind Schedule V ofthe Companies Act, 2013 and pursuant to Rule 3 of the Companies (Appointment and — Remuneration of Managerial Personnel) Rules, 2014] Refer instruction kit for filing the form All fields marked in * are mandatory Entity details 1 *CosporateKdentty Number (CIN) 2 (a) *Name of the company (b) "Address ofthe registered office ofthe company (©) "Whether the company isa public company or subsidiary of a public company (Wes/No) KMP Details 3 Particulars ofthe proposed appointee or the person in whose respect the application is filed (a) *Name 7 (b) *Director Identification number (DIN) or income-tax permanent account umber (PAN) or membership number (©) *Designation 4 *Date of the resolution by the board of directors (DD/MMUYYYY) 5 "Effective date of appointment (DDIMM/YYYY) 6 Terms and conditions including remuneration (@ Remueraton © Permont = Perannum Salary Gas) (i Perquisites Gm RS) Wid Others Ga Rey (in Total oF to Ga) Gm Rs)[arr are 36) ae AT THT | ATTIC 13 (b) Tenure of appointment “From (DDIMMYYYY) To (DDMMYYYY) 7 () *Whether the age ofthe appointee is more than 70 years CesINo) (b) *Whether the appointee had been convicted or detained under any of the Aets mentioned in Part I of Schedule V years (YesiNo) (©)* Whether the appointee is a Non-Resident in Part I of Schedule V (YesiNo) 8 (@) Whether the approval for such appointment has been obtained from the members in general meeting (estNo) (a) (i) yes, date of passing the resolution (DDIMMIYYYY) (b) SRN of related Form No, MGT-14 (for filing of Special Resolution) (©) SRN of MR.2 for obtaining Central Government's aporoval (as applicable) '9(a) Whether the appointee has been disqualified For appointment of director under seotion 164 of the Act (esiNo) (b) yes, give details Attachments Copy of Board resolution w Copy of eetiieate by the Nomination and ‘Remuneration Committe of the company, if any, tothe effet that the remuneration is as per remuneration policy of the company (©) Optional attachment(s), ifany =4 THE GAZE! TE OF INDIA : EXTRAORDINARY [Parr See. 30) {Lam authorised by the Board of Directors ofthe Company vide resolution no* Dated* (DDMM/YYYY) to sign tis is form and declare that all the requirements of ‘Companies AGL, ZUTT and THETHIET Wide thereunder in respect ofthe subject matte ofthis form and matters ineidental thereto have been complied with. [also declare that all the information given herein above is true, correct and complete including the attachments to this form and nothing material has been suppressed To be digitally signed by Designation 7 (Director/Manager!Company Secretary/CFOICEO) "Director idenifiation number of the ditestor; or DIN or PAN of the manager or CEO or CFO: or Membership number of the Company secretary Certificate by practicing professional 1 declare that I have been duly engaged for the purpose of certification of this form. Iti hereby certified that I have ‘gone through the provisions of the Companies Act, 2013 and Rules thereunder for the subject matter of this form and matters incidental thereto and I have verified the above pariculars (including attachment(s) from the originalcertified records maintained by the Company/applicant which is subject matter of this form and found them to be true, correct ‘and complete and no information material to this form has been suppressed. urther certify that 1) ‘The said records have been properly prepared, signed by the required officers of dhe Company and maintained as per the relevant provisions of the Companies Act, 2013 and were found to be in order; 2) All the required attachments have been completely and legibly attached to this form ‘To be digitally signed by © Chanered accountant (in whole ime practice) © Company secretary (in whole-time practice) Cort sceonntant (in whe time practice) Whether associate or fellow © Associate Fellow Membership number Centficate of Practice number ) Note: Attention is drawn to provisions of Section 448 and 449 of the Companies Act, 2013 which provide for Punishment for false statement / certificate and punishment for false evidence respectively. For office use only: ‘Form Service request number (SRN) ‘eForm filing date (DDIMM/YYYY)