ENROLLMENT FORM

(For Individual / Proprietor)

Connector Details

Full Name*

Date of Birth*

Father / Mother / Husband Name*

PAN Number*

e.g. ABCDE1234F

Mobile Number*

10 digits

Email ID*

Photograph

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JPG or PNG only

JPG / PNG

Address (As Per KYC)

House No. / Building Name*

Street / Area / Locality*

Town / Village*

Land Mark

City*

State*

PIN Code*

6 digits

Correspondence Address

Same as KYC Address

House No. / Building Name

Street / Area / Locality

Town / Village

Land Mark

City

State

PIN Code

6 digits

GST Details

GST Registered

Yes

Document Upload

Identity Proof (Both Required)

PAN Card*

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PDF or JPG

Aadhaar Card*

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PDF or JPG

Address Proof (Any One)

Aadhaar Card (if not used above)

Driving License

Latest Electricity Bill (<3 Months)

Latest Telephone Bill (<3 Months)

Passport

Rental Agreement + Utility Bill

Voter ID Card

Others (Please Specify)

Bank Details

Bank Name*

Account Type*

Current

Savings

Others

Bank Account Number*

IFSC Code*

e.g. SBIN0001234

MICR Code

9-digit code on cheque

Bank Address

Cancelled Cheque*

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PDF or JPG — Please attach cancelled cheque

PDF or JPG

Nominee Details

I/We wish to nominate the person named below to receive the amounts of brokerage to my credit in the event of my death.

Name of the Nominee

Date of Birth

Relationship with Connector

Address of Nominee / Guardian

Nominee / Guardian Contact No.

10 digits