REGISTRATION FORM PERSONAL DETAILS Full Name Father / Guardian Name Contact Number Permanent Address Nearest Landmark Select State Select StateAndhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest BengalAndaman and Nicobar IslandChandigarhDadra and Nagar Haveli and Daman and DiuDelhiLadakhLakshadweepJammu and KashmirPuducherry City Pin Code Telephone No Same as above YES/NO YESNO Res. Correspondence Address Nearest Landmark City Select State Select StateAndhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest BengalAndaman and Nicobar IslandChandigarhDadra and Nagar Haveli and Daman and DiuDelhiLadakhLakshadweepJammu and KashmirPuducherry Pin Mobile Your email Date* of Birth (DD/MM/YYYY) Gender MaleFemale Citizen IndianForeign Valid ID No. (Pan Card, Voter ID Card, Passport, Adhaar Card, Driving License & Any other Valid ID Proof) Select Certification Select CertificationChartered Wealth Manager® (CWM®)Chartered Trust & Estate Planner® (CTEP®)Accredited Financial Analyst® (AFA®)Chartered Economist ® (Ch.E®)Chartered Portfolio Manager ® (CPM®) Select Company Select CompanyICICIBank of BarodaHDFCAditya BirlaAxis BankCITI BankIDBIIDFCBandan BankFedral BankFedral BankSBIBank of IndiaPNBIndian Bank1 Finance Employed Details StudentSelf EmployedSalaried Self Employed Details Sole ProprietorshipPartnershipCompanyOther (Remark) Other (Remark) 1. Name of Organization: 2. Nature of Business: 3. No. of employees working in the organization: 4. Type of Industry: 5. Functional Area of Work : Mutual Fund DistributorInsurance AdviserRegistered Investment AdviserShare BrokerOther (Remark) Other (Remark) 6. What Financial products do you deal? Mutual FundsLife InsuranceHealth InsuranceSharesBondsSmall Saving ProductsFinancial PlanningOther (Remark) Other (Remark) Δ