Request Form for Freezing/Defreezing of SPEED-e service

Revocation of SPEED-e Facility Form

(For Smart Card Users-Individuals)

To, Date: ___________

DP Name : ________________

DP Id : ________________

Dear Sir/Madam,

I/We request you to revoke/discontinue as

(Tick 4 in the appropriate box below)

o Revoke Account

o Revoke Smart Card

Fill up any one or both of the following (as may be applicable)

Only specific account

First/Sole Holder Name : ____________________________________

Second Holder Name : ____________________________________

Third Holder Name : ____________________________________

Client Id : ____________________________________

User Id : ____________________________________

Reason : ____________________________________

____________________________________

Smart Card

Name of smart card owner : ____________________

Certificate Serial No. : ____________________

Smart Card Serial No. : ____________________

User Id (any one) : ____________________

Corresponding Client Id : ____________________

Reason : ___________________________________

____________________________________

(Authorised Signatory)

(to be signed by smart card user/account holder)

For office use only (to be filled up by DP. NOT TO BE FILLED UP BY CLIENT)

The application is verified with the details of the beneficial owner’s account and certify that the same is in order.

Name of the Authorised Signatory : __________________________

Signature : __________________________

(DP’s stamp and Date)

For office use (to be filled by NSDL)

Maker : _____________ Sign & Date : __________

Checker : _____________ Sign & Date : __________

Acknowledgment

Date : ______________

Received an application for revocation of account/smart card from _________________ _______________________having Client Id _____________.

(DPs Stamp & Signature)