Application Form for SPEED-e

(For Smart Card Users - Individuals)

 

To, Date:

DP Name : _________________________

I / We wish to register for SPEED-e service and intend to operate my/our demat accounts using a smart card as per the details given below:

  1. Account Details

Client Id

                

DP Id

I

N

            

Sole / First Holder’s Name

  

Second Holder’s Name

  

Third Holder’s Name

  

2. User Id preference

Preference 1 : ____________________

Preference 2 : ____________________

Preference 3 : ____________________

Allotted User Id : ____________________

(To be filled by DP. If the preferred user id is not available, DP will allot another user id)

I / We authorise the following person to operate my / our account through SPEED-e (In case of joint holders you may authorise any one of the joint holders or any other person to become a Power of Attorney for operating SPEED-e). The details of the smart card user (either the sole holder or POA holder) are given below :

Tick 4 any one of the following:

o Full smart card kit required

o Only smart card required

  1. Full Name _________________ ___________________ __________________

    2. (Last Name) (First Name) (Middle Name)

  2. Father’s Name _______________ ___________________ __________________

    3. (Last Name) (First Name) (Middle Name)

  3. Address

A. Residential Address

________________________________________________________

________________________________________________________

________________________________________________________

City ______________________ Pin : ___________

Telephone No . _______________________________________

Fax No. ______________________________________

Mobile Phone No. ______________________________________

  1. Office Address

________________________________________________________

________________________________________________________

________________________________________________________

City ______________________ Pin : ___________

Telephone No ._______________________________________

Fax No. _______________________________________

4. Address for Communication Tick Ö as applicable A or B

5. Sex Tick Ö as applicable : Male / Female

6. Date of Birth (dd/mm/yyyy) ___ / ___ / _____

7. Nationality ___________________________________

8. In case of foreign national, visa details ___________________________________

___________________________________

9. E-mail Address ___________________________________

10. Identity Details

A. Passport Details

Passport No. ___________________________________

Passport issuing authority ___________________________________

Passport expiry date ___________________________________

OR

B. Voter’s Identity Card No ___________________________________

OR

C. Income Tax PAN No. ___________________________________

11. ISP Details

ISP Name ___________________________________

ISP’s Website Address, if any ___________________________________

Your User Name at ISP, if any ___________________________________

12. Bank Details

Bank Name ___________________________________

Branch ___________________________________

Bank Account No. ___________________________________

Type of Bank Account ___________________________________

13. Type of Digital Signature Certificate required _____For NSDL SPEED-e Service__

14. No. of additional accounts to be operated _____ __

(Enclose one "Attach Additional Account to Smart Card – Individuals" for each account)

Declaration

The rules and regulations pertaining to SPEED-e service which are in force have been read and understood by me/us and I/we agree to abide by and to be bound by the same. I/We declare that the account details given above indeed belong to me/us. I/We also authorise the following individual named below to operate my/our account using SPEED-e.

 

Name

Signature

Sole/First Holder Name

  

 

Second Holder Name

  

 

Third Holder Name

  

 

(to be signed by account holders)

The rules and regulations pertaining to SPEED-e service which are in force have been read and understood by me and I agree to abide by and to be bound by the same. I declare that the information given by me is true and correct. I further agree that if any information given by me is false or misleading or any material fact is suppressed, it will render my SPEED-e service liable for termination and appropriate action.

 

Name

Signature

Sole Holder/POA Holder (Smart Card User)

  

 

(to be signed by smart card user)

For office use (DP) – Not to be filled up by Applicant

The application form is verified with the details of the beneficial owner’s account and certify that the same is in order. The proof of identity and proof of address of the smart card user is verified.

Registration Request No. : _________________________

Name of Authorised Signatory : __________________________

Signature : __________________________

(DP’s stamp & Date)

For office use (NSDL)

Token Id : _______________

Smart Card Serial No. : _______________

Certificate Serial No. : ________________

Maker : ______________ Sign. & Date : _____________

Checker : ______________ Sign. & Date : _____________

 

Instructions:

  1. Please enclose the proof of identity and proof of address of the smart card user.

    1. For proof of identity, the applicant’s signature and photograph must be authenticated by an existing account holder or by the applicant’s bank or after due verification made by the Participant of the original of the applicant’s valid passport, Voter’s Id card, driving licence or PAN card with photograph.

    2. For proof of address, applicant must submit verified copies of ration card, valid passport, Voter’s Id card, driving licence or PAN card. An authorised official of the Participant, under his/her signature, shall verify the original documents.

  2. In case of joint holders, any one of joint holders or any other person may be authorised to operate the account.

  3. Strike off whichever is not applicable.

______________________________________________________________________________________

Acknowledgment

Date : _____________

Received an application for subscribing to SPEED-e from _________________________ (sole/first holder name) having Client Id _________ .

 

(DPs Stamp & Signature)