1.CONTACT DETAILS

 

ARN No.*
EUIN No
Please Provide Certificate Date:*
NAME(Mr / Mrs / Ms / M/s)*		GENDER:	Male  Female
Correspondence Address*		EMAIL*
State*	Select your state ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHATTISGARH DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH IMPHAL JAMMU & KASHMIR JHARKHAND KARNATAKA KERALA MADHYA PRADESH MAHARASHTRA MEGHALAYA MIZORAM NAGALAND ORISSA PUNJAB RAJASTHAN TAMIL NADU TELANGANA TRIPURA UTTAR PRADESH UttaraKhand WEST BENGAL	City:*	Select your city
Pin code		Tel No:
Res.		OFF.
Mobile No.*		Fax

2. Statutory Disclosure

GST number		Tax Status:*	--Select-- Resident Individual
PAN*		Empanelled with:	BSE STAR NSE MFSS NSE NMF II

Service Tax No.*
Tax Status:*	--Select-- Resident Individual Body Corporate HUF Sole Properietorship Foreign Company Partnership Firm NRI Others
PAN*
Copy of PAN Card attached*
Empanelled with: *	BSE STAR NSE MFSS NSE NMF II	KYD Compliance is mandatory (Please attach a copy of the KYD Acknowledgement Letter)*

3. Business Details

 

Office Area(Sq.Ft):*		No. of Computers:*
No. of Branches:*		No. of Employees:*
Geographical Areas Covered:*		Fund Houses empanelled with:*
Experience :*		Total no. of Investors Serviced:*
Total no. of Sub-brokers:*		Equity AUM: (Rs.)*
Debt AUM : (Rs.)*		Total AUM: (Rs.)*
No. of Investors*		Experience in Business : (in years)*

4. Disclosures( Note: If any of the below criteria is met, you need to complete a due diligence process before empanelment.)

a. Multiple point presence (More than 20 locations)*	YES   NO
b. AUM raised over Rs. 100 Crore across industry in the non institutional category including high networth individuals (HNI’s)*	YES   NO
c. Commission received of over Rs. 11 Crore p.a. across industry*	YES   NO
d. Commission received of over Rs. 50 Lakh from a single Mutual Fund	YES   NO
Note: If any of the above criteria is met, you need to complete a due diligence process before empanelment.

5. BANK ACCOUNT DETAILS (Your commission / brokerage payments will be paid by direct credit to this account)

 

Bank Name*		Account Number*
Bank Branch Address*		Pin code
State*		City*
IFSC Code*		MICR Code *

6. Nomination facility: (Available only for individuals)

 

Name of the Nominee:		Relationship with you:
Nominee's Address:
State	Select your state ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHATTISGARH DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH IMPHAL JAMMU & KASHMIR JHARKHAND KARNATAKA KERALA MADHYA PRADESH MAHARASHTRA MEGHALAYA MIZORAM NAGALAND ORISSA PUNJAB RAJASTHAN TAMIL NADU TELANGANA TRIPURA UTTAR PRADESH UttaraKhand WEST BENGAL	City	Select your city
Pin Code

7. Declaration:

	I / We hereby declare that the information provided is factual and correct. I / We understand that if any information is found to be incomplete, false
	or wrong, then the BOIIM may take suitable action against me including termination of empanelment / Distribution Agreement. I / We further confirm
	that all our personnel, sub-agents are certified and registered with AMFI and hold a valid AMFI certificate and photo-identity card.

8.TERMS AND CONDITIONS

Accept the Terms and Conditions. Click here for Terms and conditions.