[A] IDENTITY DETAILS 1 ) Name of the applicant 2) Date of incorporation Place of incorporation 3) Date of commencement of business 4) Pan Number Registration No. (e.g. CIN) 6) Status (please select any one) Private Limited Co.Public Ltd. Co.Body CorporatePartnershipTrustCharitiesNGO’sFIFIIHUFAOPBankGovernment BodyNon-Government OrganizationDefense EstablishmentBOISocietyLLPOthers [B] ADDRESS DETAILS 1) Address for correspondence City/town/village Pin Code State Country 2) Contact Details Tel. (Off.) Tel. (Res.) Mobile Number Fax Number Email id 3) Specify the proof of address submitted for correspondence address 4) Registered Address (if different from above) City/town/village Pin Code State Country 5) Specify the proof of address submitted for Registered Address [C] OTHER DETAILS 1) Gross Annual Income Details (please specify) Income Range per annum Below Rs 1 Lac1-5 Lac5-10 Lac10-25 Lac25 Lac - 1 crore> 1 crore 3) Net-worth as on (date) (Net worth should not be older than 1 year) 3) Name, PAN, residential address and photographs of Promoters/Partners/Karta/Trustees and whole time directors Name of the Promoters/Partners/Karta/Trustees and whole time directors Pan Number of the directors residential address of the directors Upload Photos 4) DIN/UID of Promoters/Partners/Karta and whole time directors 5) Please tick, if applicable, for any of your authorized signatories/Promoters/Partners/Karta/Trustees/whole time directors Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP) 6) Any other information I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to 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/we are aware that I/we may be held liable for it.