z'esfdgf ;]So'l/6Lh k|f= ln= :6s a|f]s/ g+=

-xfn;fn}
71 Shubhakamana Securities Pvt. Ltd. &!
lvr]sf]
gf/fo0frf}/, gS;fn, sf7df8f}+ . kf;kf]6{ ;fO{hsf]
g]kfn lwtf]kq af]8{af6 cg'dlt k|fKt
kmf]g g+= )1–5918829÷5918830 kmf]6f]_
Od]n M [email protected]
kmf]6f]df kg]{ u/L x:tfIf/
k|fs[lts JolQmsf] kl/ro ljj/0f
DETAILS OF NATURAL PERSON
cg';"rL–!@
-lgod @( sf] pklgod -!_ ;Fu ;DalGwt_

sfof{no k|of]hgsf] nflu dfq -For Official Use Only_

u|fxs gDa/ ;+s]t gDa/ ldlt
(Clients A/C No.): (ReferenceNo.): (Date):

tn pNn]lvt ;Dk"0f{ ljj/0f /fd|f];Fu eg'{ kg]{5 . cfkm';Fu ;/f]sf/ gePsf] ljj/0f pNn]v ug]{ sf]7fdf t];f]{ wsf{ tflglbg' xf]nf .
Please Complete all details and strike out the non-applicable fields/boxes.

u|fxssf] ljj/0f (Details of Client):

gfd
Name (in Block Letter)

hGd ldlt -lj=;+=_ O{=;+= lnË÷Gender:

Date of Birth (B.S.) (A.D.)
k'?if dlxnf cGo
Male Female Others

/fli6«otf÷(Nationality) g]kfnL÷Nepalese cGo -v'nfpg]_÷Others (If any)

gful/stf g+= hf/L lhNnf hf/L ldlt
(Citizenship No.) Issue District Issue Date

lxtu|fxL vftf g+=÷Beneficiary ID No.

:yfoL n]vf g+=÷Permanent Account No. (PAN)
u}/ cfjf;Lo g]kfnLsf] xsdf kl/ro kq g+= / 7]ufgf
Identification No. and address (In case of NRN)

:yfoL 7]ufgf (Permanent Address):

b]z (Nation): k|b]z (Province): lhNnf (District):

uf=kf=÷g=kf=÷p=d= g= kf=÷
d=g=kf=(R.M/M/SM/Metro) 6f]n (Locality): j8f g+= (Ward No.):

6]ln kmf]g g+=(Tele Phone No.): km\ofS; g+=(Fax No.): Ans g+= (Block No.):

df]afO{n g+=(Mobile No.) O{d]n (E-mail):

xfnsf] 7]ufgf (Current Address):

b]z (Nation): k|b]z (Province): lhNnf (District):

uf=kf=÷g=kf=÷p=d= g= kf=÷
d=g=kf=(R.M/M/SM/Metro) 6f]n (Locality): j8f g+= (Ward No.):

6]ln kmf]g g+=(Tele Phone No.): km\ofS; g+=(Fax No.): Ans g+= (Block No.):

df]afO{n g+=(Mobile No.) O{d]n (E-mail): (What's App/Viber No.):

 k]zfsf] ljj/0f (Details of Occupation):

k]zf ;]jf ;/sf/L ;fj{hlgs÷lghL If]q Pg=hL=cf]=÷cfO{=Pg=hL=cf]= ljz]if1

Occupation Service Government Public/Private Sector NGO/INGO Expert
Jofkf/L s[lif ;]jflgj[t u[lx0fL ljBfyL{ cGo
Business Person Agriculture Retired House wife Student Others

Jofkf/sf] k|sf/ pTkfbg ;]jfd'vL cGo

Type of Business Manufacturing Service Oriented Others

;+:yfsf] gfd
Organization's Name
7]ufgf
Address
kb sd{rf/Lsf] xsdf sd{rf/L kl/ro kq g+=
Designation ID No. of Employee
cfly{s ljj/0f cfosf] ;Ldf -jflif{s ljj/0f_ ?= %,)),))) ;Dd ?= %,)),))! b]lv ?= !),)),))) ;Dd ?= !),)),))) eGbf dfly
Financial Details Income limit/Annual Detail Upto Rs. 5,00,000 From Rs. 5,00,001 to Rs. 10,00,000 Above Rs. 10,00,000
lwtf]kq vl/b laqmL ug]{ d'Vo p2]Zon] :yflkt O{Ge]i6d]G6 sDkgLdf ;+nUg 5'÷Yes 5}g÷NO
Involvement in investment companies which were established for securities trading
ePdf b]xfo adf]lhdsf] ljj/0f pNn]v ug'{ kg]{ . (If yes, mention below):
sDkgLsf] gfd
Name of the Company
kb ;~rfns kbflwsf/L z]o/wgL sd{rf/L cGo
Designation Director Executive Share Holder Employee Others

Psf3/ kl/jf/sf ;b:ox?sf] ljj/0f (Details of Family Members):

a'afsf] gfd
Father's Name

afh]sf] gfd
Grand Father's Name

cfdfsf] gfd
Mother's Name

klt÷kTgLsf] gfd
Spouse's Name

5f]/fsf] gfd
Son's Name

5f]/Lsf] gfd
-cljjflxt_
Daughter's Name
(Unmarried)

a'xf/Lsf] gfd
Daughter in Law's Name

;;'/fsf] gfd -ljjflxt

dlxnfsf] xsdf_
Father in Law's Name
(In Case of Married Women)
;f;'sf] gfd -ljjflxt
dlxnfsf] xsdf_
Mother in Law's Name
(In Case of Married Women)
 a}+s vftf ljj/0f (Bank Account Details):

a}+ssf] gfd (Bank Name): zfvf (Branch):

vftf g+= (A/C No.):
vftf lsl;d (Type of A/C): art vftf (Saving A/C) rNtL vftf (Current A/C)

;+/Ifssf] ljj/0f -gfafnssf] xsdf_÷Guardian's Information-In case of minor:

;+/Ifssf] gfd÷y/
Name/Surname
(In Block Letter)

lgj]bs;Fusf] ;DaGw
Relationship with Applicant ;+/Ifssf] kmf]6f]
-xfn;fn} lvr]sf]_
kqfrf/ ug]{ 7]ufgf÷Correspondence Address
Guardian's
PP Size Photo
b]z k|b]z lhNnf (Recent)
Country Province District

uf=kf=÷g=kf=÷p=d=g=kf÷
dxfgu/kflnsf j8f g+= 6f]n kmf]g g+=
R.Mun./Mun./Sub Met Ward No. Tole Tel. No.
Metropolitan
df]afO{n g+= km\ofS; g+= :yfoL n]vf g++
Mobile No. Fax No. PAN No.

O{d]n÷E-mail ID

;+/Ifssf] x:tfIf/÷Guardian's Signature

af;:yfgsf] gS;f ÷ Location Map of Residence

Site Map of the Account Holder's Residence with nearby popular mailstone
↓
N
3/ /x]sf] :yfgsf] gS;f
Location Map

if the Residence is ................................ meters (approximatery).

 lwtf]kq sf/f]af/ ;DaGwdf tklzn adf]lhdsf] :j3f]if0ff ub{5' . ÷ I/We hereby decleare by following:
1= d÷xfdLn] lwtf]kq vl/bsf nflu k|of]u ug]{ /sd ;Dklt z'l4s/0f ;DaGwL k|rlnt sfg"g ljkl/t cfh{g u/]sf] x'g] 5}g .
I/We hereby confirm that funds used to purchase the shares have not been acquired by any means voilating prevailing Anti Money
laundering act.
2= lwtf]kqdf ul/Psf] nufgLdf lglxt hf]lvdsf] ;DaGwdf hfgsf/ 5' .
I/We fully understand the risks associated with respect to investing in stocks/Securities.
3= d÷xfdLn] vl/b u/]sf lwtf]kqx? afktsf] e'QmfgL lng] lbg] sfo{ tf]lsPsf] ;do leq ug]{ 5' .
I/We will duly comply the payment terms, required for purchase/sale of shares/securities.
4= d÷xfdLn] lwtf]kq ;DaGwL tyf cGo k|rlnt lgod sfg"gx?sf] kfngf ug]{5' .
I/We will fully comply the prevailing laws related to stock market/securities.
5= d÷xfdL shf{ ;"rgf s]Gb|sf] sfnf] ;"rLdf /x]sf] 5'÷5}g .
I/We am/are not included in the black list of credit information bureau.
;+nUg ug'{kg]{ sfuhftx¿M Documents required:
1= g]kfnL gful/sx¿sf] xsdf gful/stfsf] k|df0fkqsf] k|ltlnlk .
Copy of citizenship certificate (Incase of Nepali citizens)
2= cGo b]zsf] gful/ssf] xsdf kf;kf]6{sf] k|ltlnlk .
Copy of Passport (Incase of Foreign Citizens)
3= gfafnssf] xsdf ;+/Ifs tyf gfafns b'a}sf] kmf]6f] .
Photograps of Guardian & minor (Incase of minor)
4= sfg"gL ;+/Ifs eP ;f] ;DaGwL sfuhft .
legal Guardian related documents, if applicable.
5= cfdf jf afa' ;+/Ifs ePdf 5f]/f jf 5f]/Lsf] hGd btf{sf] k|df0fkqsf] k|ltlnlk .
Copy of birth registration certificate (Incase of minor)
6= lgj]bssf] x:tfIf/ tyf cf}+7f 5fkdf ;+/Ifssf] x:tfIf/ tyf cf}+7f 5fk .
Signature and finger print for the applicant and minor (where applicable)
7= s'g} ;+:yfsf] sd{rf/L /x]sf] xsdf sd{rf/L kl/rokqsf] k|ltlnlk .
Copy of employee identification if working at any organization.
dfly pNn]lvt ljj/0f ;To tYo /x]sf] / ;f] ljj/0fdf s'g} km/s k/] sfg"g adf]lhd ;x'Fnf, a'emfpFnf .
I/We hereby acknowledge that the above disclosed details are true. I/We, further hereby consent to bear any legal actions in case
any false disclosure of information related to me/us.

cf}+7f 5fk÷Thumb Print

Right Left

Signature of Customer
u|fxssf] x:tfIf/
ldlt
Date

sfof{no k|of]hgsf] nflu M For Official Use

Checked & Verified by Approved by

Signature Signature

Name Name

Designation Designation
sDkgLsf] 5fk
Date Date
Shubhakamana Securities Pvt. Ltd.

Risk Category: Low Risk Medium Risk High Risk* PEP Yes* PEP Associate PEP
No
Referrer Name Contact