DISTRUBUTOR EMPANELMENT FORM(Only for Resident Individual)

ARN No.*
Please Provide Certificate Date:*
NAME(Mr / Mrs / Ms / M/s)* GENDER:  
Correspondence Address* EMAIL*
State* City:*
Pin code Tel No:
Res. OFF.
Mobile No.* Fax
RM Name
2. Statutory Disclosure
GST number Tax Status:*
PAN* Empanelled with:
Service Tax No.*
Tax Status:*
Copy of PAN Card attached*
Empanelled with: * KYD Compliance is mandatory (Please attach a copy of the KYD Acknowledgement Letter)*
3. Business Details
Office Area(Sq.Ft): No. of Sales Employees:
No. of Branches: Total no. of Sub-brokers:
Experience in Business : (in years) Total AUM (Funds Mobilised): (Rs.)
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)*   
b. AUM raised over Rs. 100 Crore across industry in the non institutional category including high networth individuals (HNI’s)*   
c. Commission received of over Rs. 1 Crore p.a. across industry*   
d. Commission received of over Rs. 50 Lakh from a single Mutual Fund   
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*
IFSC Code*   MICR Code  
Bank Branch Address*
6. Nomination facility: (Available only for individuals)
Name of the Nominee: Relationship with you:
Nominee's Address:
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.      
  - I/We am/are not an Employee or a relative of a Director/Employee of the AMC/Sponsor/or any of its associates.      

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