-'upstox

PLEASE AFFIX A
Know Your Client (KYC) RECENT PASSPORT
Application Form (For Individuals Only) PHOTOGRAPH AND
Please fill type the form in English and BLOCK letters. Sign all areas marked with SIGN ACROSS IT
'x'. Once completed, please mail the completed form along with the necessary
proofs to our corporate office in Mumbai. CLIENT'S SIGNATURE fl]

A. Identity Details (please see guidelines)

FULL NAME (As appearing in supporting identification document):

FATHER / SPOUSE'S NAME: MAIDEN NAME: (If any)

MOTHER NAME:
GENDER O MALE O FEMALE O T -TRANSGENDER MARITAL STATUS O MARRIED O UNMARRIED

CITIZENSHIP O IN -INDIAN O OTHER DATE OF BIRTH (dd/mm/yyyy)

RESIDENTIAL STATUS 0 RESIDENT INDIVIDUAL O NON RESIDENT INDIAN O FOREIGN NATIONAL 0 PERSON OF INDIAN ORIGIN

PAN (Please enclose a duly attested copy) Applicant E-Sign

PROOF OF IDENTITY SUBMITTED FOR PAN EXEMPT CASES (Please Tick✓)

0 A-Aadhar Card XXXXXXXX ______

D B-Passport Number

0 C-VoterlD

D D -Driving License

0 E -NREGA Job Card

0 F -NPR
D z-Others ___________
(anydocumentbyCentralGovernment)

Identification Number

B. Address Details {Please see guidelines)

Address Type D Residential/ Business D Residential D Business D Registered Office D Unspecified

ADDRESS FOR RESIDENCE/CORRESPONDENCE:

CITY/TOWN/VILLAGE:
----------- STATE: PIN CODE

DISTRICT: COUNTRY:

PERMANENT ADDRESS OF RESIDENT APPLICANT IF DIFFERENT FROM ABOVE Bl OR OVERSEAS ADDRESS(MANDATORY) FOR NON RESIDENT APPLICANT:

CITY/TOWN/VILLAGE:
----------- STATE: PIN CODE
DISTRICT: COUNTRY:

PROOF OF ADDRESS' (attested copy of any 1 POA for correspondence and permanent address each to be submitted)

0 A-Aadhar Card _
XXXXXXXX _ _ _ _ _

D B-Passport Number
------------ Exp;ryoate

□ C-VoterlD

D D -Driving License ____________

Expiry Date

0 E -NREGA Job Card

0 F -NPR
Dz-Others (any document by Central Government)

Identification Number

PAGE4
V3.l.0
 C. Contact Details (in CAPITAL)

EMAIL ID*

MOBILE NO.*

TEL (Off) TEL (Res)

D. Applicant Declaration

I/We hereby declare that the KYC details furnished by me are true and correct to the Applicant e-SIGN Applicant Wet Signature
best of my/our knowledge and belief and I/we under-take to inform you of any ----------- -----------
f-- -+- ----i
changes therein, immediately. In case any of the above information is
found to be false or untrue or misleading or misrepresenting, I am/We are
aware that I/We may be held liable for it.
I/We hereby consent to receiving information from CVL KRA 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 the entire account opening form along with supporting
documents as applicable, with KRA and other Intermediaries with whom I have a
business relationship for KYC purposes only.

Place

Date

FOR OFFICE USE ONLY

1----------------------�
I IPV Done D on (dd/mm/yyyy)
AMC/Intermediary name OR code
D (Originals verified) True copies of
Application Type □ New D Update
Seal/Stamp of the intermediary should contain
documents received KYC Number (Mandatory for KYC update request)
Staff Name
Designation
Name of the Organization
D (Attested) True copies of documents
Account Type □ Normal D Small
Signature
Date
received Main Intermediary Place
D Simplified

KYC Mode* 0 Normal O EKYC OTP O EKYC Biometric O Online KYC O Offline KYC O Digilocker

DECLARATION FOR NAME MISMATCH

(To be filled if the name on documents is different)

This is to bring to your notice that my name is spelt differently in my Identity proof, Address proof and Bank proof. Please find below the
names as spelt in respective proofs:

Name as per Income Tax

Name as per Bank Proof

Name as per Address Proof

Name as per Income Proof

I hereby confirm that all the said names belong to me. I hereby state and confirm that what is stated above is true and correct information.
I agree to indemnify and keep Upstox Securities Pvt. Ltd./ RKSV Commodities India Pvt. Ltd.indemnified at all times from and against all
costs, charges, damages, penalties (including reasonable attorney fees) suffered and/or incurred by Upstox Securities Pvt. Ltd./ RKSV
Commodities India Pvt. Ltd. for any act done or omitted to be done on the above declaration.

CLIENT'S SIGNATURE [12] X

PAGES
V 3.1.1