Beruflich Dokumente
Kultur Dokumente
1. Online FAN payout form (For detailed please refer circular dated
February 09, 2009, ref no. 2009/02/019, subject: Compulsory
online FAN payout for FAN-P). Required documents –
1)Cancelled cheque
2) Latest Bank statement [not more than 3 months old]
(Required only if name on cancelled cheque is not pre-printed)
4. Covering letter
5 Registration Fees
6 Deposit
7. Undertaking
(1.) Individual
(2.) Proprietor
City: Taluka:
Dist: State: PIN Code:
Residence address
City: Taluka:
Dist: State: Pin Code:
Contact detail Office :
Resi :
Mobile :
E – Mail ID :
Whether business & residence address
same Yes / No
PAN Card No.
FAN Terms
Deposit Cheque : Rs.
Shares ( ‘A’ Category ) : Rs.
Sharing Terms
VSAT Required (Yes / No)
INFRASTRUCTURE DETAILS
Office (Owned / Rented)
Office Area Sq. ft. :
NCFM Certificate details
NSE Cash Name: No:
BSE Cash Name: No:
Derivatives Name: No:
Current Broking Tie Ups
Yes / No (If Yes)
Specify the details of company with
existing Proposal
No. of Clients
Brokerage Structure
Brokerage sharing pattern
Gross Brokerage avg. per month (for 6
months)
Is there any IndiaiInfoline Branch
nearest to your office? Yes / No
(If Yes)
Specify the distance in kilometers with
complete address of Branch
Signature
Financial Status / Net Worth
Educational Qualification
FAN Referred by Name: Emp. Code:
FAN Introduced by Name: Emp. Code:
FAN Managed by Name: Emp. Code:
Location / Code of branch who handles
this FAN Name: Branch Code:
Immediate
Authority of
above RM
For Office use:
FAN code
Approved By Name :
Signature :
Date
Infra Requirement: - 3 Computers, Dot Matrix printer, Scanner, 3 Telephone lines &
UPS
Manpower: - 2 Dealers / RM’s & 1 Support Staf
If Certificates are not available then submit the same at the time of Compliance
formalities.
To,
India Infoline Ltd.
3rd Floor, IIFL House
Sun Infotech Park,
Road No.16V, Plot No. B 23,
MIDC, Thane Industrial Area,
Wagle Estate, Thane-400604.
Dear Sir,
With reference to the above, I am interested in associating with you for all your products
including BSE Remisiership, BSE Subbrokership, NSE Subbrokership, MCX-SX
Subbrokership, BSE Authorized Person, NSE Authorized Person, MCX-SX Authorised Person,
Mutual Fund and Insurance distribution.
You can note my email Id & mobile No. for future communication as below:
Email Id:
Mobile Number:
Thanking you,
Yours faithfully
3 Segment BOTH
1. Cash Segment 2. Derivatives Segment
3. Both
I certify that the information given in this application form is true to the best of my/our
knowledge and belief.
I/We hereby confirm/declare/undertake that the SEBI has not taken any action like
cancellation of registration / or debarred or prohibited any of the applicant /s from
dealing in securities market/imposed penalty after adjudication/prosecution etc. against
any of the applicant/s (names as applicable)
Signature of Applicant
Individual / Proprietor
(with rubber stamp)
Date:
Annexure - 2
Undertaking
I Mr./Ms. SHIV SHANKAR BHOOTRA (name of the applicant authorised person) had
applied for appointment as Authorised Person of the Stock Exchange on
Capital Market
Currency Derivatives
segment (s) through trading member, M/s.India Infoline Limited, In this regard, I hereby
confirm/undertake that:
1. I have not been convicted for any offence in the past and presently and not under trial for
any offence involving fraud and dishonesty.
2. I will deal with investors on behalf of Trading Member only and that I would not engage in
any activities with investors which could result in unauthorised intermediations.
3. I am neither an Authorised Person of any other member of the stock exchange and nor
has/have applied for appointment as Authorised Person with any other member of the stock
exchange.
4. I confirm that I am not a defaulter/expelled on any stock exchange.
5. I confirm that I am “fit and proper” under SEBI (Intermediaries) Regulations, 2008 and no
action has been taken against me by SEBI, RBI, etc. and I have not defaulted in payment to
any agency.
Date: ______________
_________________________________
* Name, Signature & Seal
Undertaking
SHIV SHANKAR BHOOTRA
MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in
I/We, Mr./Ms./M/s SHIV SHANKAR BHOOTRA (name of the applicant/ authorised person)
had applied for appointment as Authorised Person of the National Stock Exchange of India
Limited (“NSE”) Bombay Stock Exchange (“BSE”) , (NSE and BSE collectively referred to as
“Exchanges”) on Capital Market / Futures & Options / Currency Derivatives Segment(s)
through India Infoline Limited (“the Trading Member”). In this regard, I/We hereby
confirm/undertake that:
Date: ______________
Place: ______________ _________________________________
*Name, Signature & Seal
To,
Membership Compliance,
Bombay Stock Exchange Ltd.
Date:
Dear Sir,
We herby confirm that our representative has personally verified aforesaid address and it is complete in
all respect. We are also attaching AADHAR CARD as an address proof as per Exchange requirement.
I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.
Yours faithfully
Authorised Signatory
SHIV SHANKAR BHOOTRA
MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in
To,
Membership Compliance,
National Stock Exchange Ltd.
Date:
Dear Sir,
Trade Name of Authorised Person : -SHIV SHANKAR BHOOTRA, having address : MAHESHWARI
KI GALI, INSIDE CHANDPOLE, JODHPUR, JODHPUR, RAJASTHAN - 342001
We herby confirm that our representative has personally verified aforesaid address and it is complete in
all respect. We are also attaching _AADHAR CARD as an address proof as per Exchange
requirement.
I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.
Yours faithfully
Signature of Applicant
Proprietor / Partner / Director
(with rubber stamp)
Date:
Bank Sign Verification letter for BSE and NSE
Date :
From :-
To,
Respected sir,
Thanking you,
Yours Faithfully,
Dear Sir,
With reference to the above subject, you are requested to transfer my monthly payout to below
mentioned bank account
FAN Code
FAN Name
Fan Address
Thanking You,
Authorized Signatories
SHIV SHANKAR BHOOTRA
MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in
Date :
From
……………………………….
………………………………
………………………………
…………………………………
To
M/S India Infoline Ltd
Mumbai.
Please Acknowledge
Undertaking
Subject: Not to deal with Trading Member (TM) other than TM/Broker where registered
___________________________________________________________________________
I further confirm that ______________________________ is/ was not ever associated with
_____________________________________________________________
_________________________________________________________________
_________________________________________________________________
I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.
Place:
Date: (Signature)
Pan No:
I further confirm that ______________________________ is/ was not ever associated with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.
_________________________
(Signature & Stamp)
Place:
Date: (Signature)
Pan No :