Know Your Client (KYC)

Application Form (For Individuals Only)

Please fill the form in ENGLISH and in BLOCK letters

Fields marked * are mandatory Application Number:
Fields marked ⁺ are pertaining to CKYC and mandatory only if processing
Application Type* New KYC Modification KYC
CKYC also
.
KYC Mode*: Please Tick (✓)
Normal EKYC OTP EKYC Biometric Online KYC Offline EKYC Digilocker

1. Identity Details (please refer guidelines overleaf)

PAN* I V Z P K 6 9 0 6 B Please enclose a duly attested copy of your PAN Card

Name* (same as ID proof) MR. AKSHAY RAMDAS KHAIRMODE

Maiden Name⁺ (if any)

Fathers/Spouse's Name* MR RAMDAS

Date of Birth* 1 6 0 7 2 0 0 1

Gender* Male Female Transgender

Marital Status* Single Married

Nationality* Indian Other

Residential Status* Resident Individual Non Resident Indian

Please Tick (✓) Foreign National Person of Indian Origin

(Passport mandatory for NRIs, PIOs and Foreign Nationals)

Proof of Identity (POI) submitted for PAN exempted cases (Please tick)
A - Aadhaar Card XXXX XXXX 4 3 8 8

B - Passport Number (Expiry Date)

C - Voter ID Card

D - Driving Licence (Expiry Date)

E - NREGA Job Card

F - NPR

Z - Others (any document notified by Central Government)

Identification Number

2. Address Details* (please refer guidelines overleaf)

A. Correspondence/ Local Address*

Line 1* 128/5B HANUMAN NAGAR PUNE CITY

Line 2 PUNE

Line 3

City/Town/Village* PUNE CITY District* PUNE Pin Code* 411030

State* MAHARASHTRA Country* INDIA

Address Type* Residential/Business Residential Business Registered Office Unspecified

Applicant e-SIGN

Akshay Ramdas Khairmode

06 Apr 2024 at 14:00:48 IST (UTC+05:30) Aadhaar

eSign

Kotak Investment Advisors Ltd. | Type of Registration: Non - individual | Registration number: U65990MH1994PLC077472 | Validity of registration: Perpetual
Address of Investment Adviser: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400051, Phone No.: +91 22 43360701
SEBI Regional/Local Office Address: https://www.sebi.gov.in/contact-us.html
 B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)

Line 1*

Line 2

Line 3

City/Town/Village* District* Pin Code*

State* Country*

Address Type* Residential/Business Residential Business Registered Office Unspecified

Proof of Address* (attested copy of any one POA to be submitted)

A - Aadhaar Card XXXX XXXX 4 3 8 8

B - Passport Number (Expiry Date)

C - Voter ID Card

D - Driving Licence (Expiry Date)

E - NREGA Job Card

F - NPR

Z - Others (any document notified by Central Government)

Identification Number

3. Contact Details

Email ID [email protected]

Mobile No. + 9 1 - 7 8 2 1 8 4 5 7 3 7

Tel (Off) Tel (Res)

4. Applicant Declaration
I hereby declare that the details furnished above are true and correct to the best of my/our Applicant e-SIGN Applicant Wet Signature
knowledge and belief and I under-take to inform you of any changes therein, immediately. In
case any of the above information is found to be false or untrue or misleading or aa
misrepresenting, I am/We are aware that I/We may be held liable for it.
I/We hereby consent to receiving information from CVL KRA through SMS/Email on the
above registered number/Email address.
I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be
Akshay Ramdas Khairmode
validated against Aadhaar details.I/We hereby consent to sharing my/our masked Aadhaar
card with readable QR code or my Aadhaar XML/Digilocker XML file, along with passcode 06 Apr 2024 at 14:00:48 IST (UTC+05:30) Aadhaar
eSign

and as appicable, with KRA and other Intermediaries with whom I have a business
relationship for KYC purposes only.

DATE: 0 6 0 4 2 0 2 4 (DD-MM-YYYY)

PLACE: PUNE CITY

5. For Office Use Only

In-Person Verification (IPV) carried out by* Intermediary Details*

IPV Date Self certified document copies received (OVD)

Emp. Name True Copies of documents received (Attested)

Emp. Code AMC / Intermediary Name:

Emp. Designation KOTAK INVESTMENT ADVISORS LIMITED

Kotak Investment Advisors Ltd. | Type of Registration: Non - individual | Registration number: U65990MH1994PLC077472 | Validity of registration: Perpetual
Address of Investment Adviser: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400051, Phone No.: +91 22 43360701
SEBI Regional/Local Office Address: https://www.sebi.gov.in/contact-us.html
 PAN Card Copy

Pan verified with income tax site

Akshay Ramdas Khairmode

06 Apr 2024 at 14:00:48 IST (UTC+05:30) Aadhaar Kotak Investment Advisors Ltd. | Type of Registration: Non - individual | Registration number: U65990MH1994PLC077472 | Validity of registration: Perpetual
eSign
Address of Investment Adviser: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400051, Phone No.: +91 22 43360701
SEBI Regional/Local Office Address: https://www.sebi.gov.in/contact-us.html
 OFFLINE XML BASED KYC DATA FORM

This is the document generated by Kotak Investment Advisors Limited with resident's
consent and on the basis of offline XML based KYC data shared by the resident with
Kotak Investment Advisors Limited for the purpose of opening Investment Account.
This document will be used as ID and/or Address proof for record purposes.
Reference Id: UKC:42d11758f95a01b57818dc11284159e6202404061
35826
Photo

Aadhaar Number xxxxxxxx4388

Name Akshay Ramdas Khairmode
DATE OF BIRTH 16-07-2001
Gender MALE
Address 128/5B, Hanuman Nagar,Pune
City,Pune,Maharashtra,India-411030
Generated ON 04/06/2024

Akshay Ramdas Khairmode

06 Apr 2024 at 14:00:48 IST (UTC+05:30) Aadhaar Kotak Investment Advisors Ltd. | Type of Registration: Non - individual | Registration number: U65990MH1994PLC077472 | Validity of registration: Perpetual
eSign
Address of Investment Adviser: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400051, Phone No.: +91 22 43360701
SEBI Regional/Local Office Address: https://www.sebi.gov.in/contact-us.html
 Customer Signature - for CVL KRA registration

Signature image is obtained online from customer and is being shared basis customer consent

Signature panel

Akshay Ramdas Khairmode

06 Apr 2024 at 14:00:48 IST (UTC+05:30) Aadhaar Kotak Investment Advisors Ltd. | Type of Registration: Non - individual | Registration number: U65990MH1994PLC077472 | Validity of registration: Perpetual
eSign
Address of Investment Adviser: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400051, Phone No.: +91 22 43360701
SEBI Regional/Local Office Address: https://www.sebi.gov.in/contact-us.html