Nomination Form
[Annexure A to SEBI circular No. SEBI/HO/MIRSD/RTAMB/CIR/P/2021/601 dated July 23, 2021 on Mandatory Nomination for Eligible Trading and Demat Accounts]

                        TM / DP
B R JALAN SECURITIES PRIVATE LIMITED                                              
903 MARATHON ICON LOWER PAREL MUMBAI 400013
	FORM  FOR  NOMINATION
	
(To be filled in by individual applying singly or jointly)	
Date									UCC/ DP  ID	1	2	0	1	8	9	0	0	Client ID	0	0	0						
I/We the sole holder / Joint holders / Guardian (in case of minor) hereby declare that: 
	
I/We wish to make a nomination. [As per details given below]	
Nomination Details	
I/We wish to make a nomination and do hereby nominate the following person(s) who shall receive all the assets/ security balances held in my / our account particulars whereof are given below in the event of my / our death of the Sole holder or the death of all the Joint Holders.
	
Nomination can be made upto three nominees in the account.	Details of 1st Nominee	Details of 2nd Nominee	Details of 3rd Nominee	
1	Name of the nominee(s) (Mr./Ms.)				
2	Share	of each Nominee	Equally
[If not equally, please specify percentage]	%	%	%	
			Any odd lot after division shall be transferred to the first nominee mentioned in the form.	
3	Relationship With the Applicant ( If  Any)				
4	Address of Nominee(s)

City / Place: State & Country:				
		PIN Code							
5	Mobile    /    Telephone    No.    of nominee(s)				
6	Email ID of nominee(s)				
7	Nominee Identification details – [Please tick any one of following and provide details of same]
 
󠄀 Photograph & Signature 󠄀 PAN
󠄀 Aadhaar 󠄀 Saving Bank account no. 󠄀 Proof of Identity 󠄀 Demat Account ID				
Sr. Nos. 8-14 should be filled only if nominee(s) is a minor:	
8	Date of Birth {in case of minor nominee(s)}				
9	Name of Guardian (Mr./Ms.) {in case of minor nominee(s) }				
10	Address of Guardian(s)				

City / Place: State & Country:	

	

	
PIN Code				
*Residual Securities   [please tick any one nominee.
If tick not marked default will be first nominee]:	

	
11	Mobile    /    Telephone    no. Guardian	of				
12	Email ID of Guardian					
13	Relationship  of guardian  with nominee					
14 Guardian Identification details –
 [Please tick any one of following 
and provide details of same]

󠄀 Photograph & Signature
󠄀 PAN  󠄀 Aadhaar Saving Bank
 account no.
   󠄀 Proof of Identity󠄀
󠄀 Demat Account ID

	

	

	
         	        Name(s) of holder(s)	                                Signature(s) of holder*	
Sole / First Holder (Mr./Ms.)			
Second Holder (Mr./Ms.)			
Third Holder (Mr./Ms.)			
This nomination shall supersede any prior nomination made by me / us and also any testamentary document executed by me / us.
	
* Signature of witness, along with name and address are required, if the account holder affixes thumb impression, instead of signature
Note: This nomination shall supersede any prior nomination made by the account holder(s), if any.

Nomination Form accepted and registered wide Registration No. _____________________ dated ______________.

For Depository Participant 
(Authorised Signatory)