1.CONTACT DETAILS

 

ARN No.*
EUIN No
Please Provide Certificate Date:*
NAME(Mr / Mrs / Ms / M/s)*		GENDER:	Male  Female
Correspondence Address*		EMAIL*	please enter valid email id
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 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)*	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. 1 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*
IFSC Code*	Please Enter Valid IFSC code	MICR Code	Enter Valid 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.

8.TERMS AND CONDITIONS

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