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
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 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)*   
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. 11 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*
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 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.      

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