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Annex-l-2

(fqfu{q ?" fr{ s'qfud)(Pursuant to Byelarv 2O)

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s["i. cForm No.: 1

o.rstoq 9-qts{6l 6rFI qra (ForOfficialUse Only)

eTffEq "I<[t Application No.:

fiil qrw Symbol No.:

frfr Date:

a-o irdfua Hqoi fus-{ur qrt'rtr r q-j t1{u I enqf,rr str5.n qq1rdl G-agq \3-dq .r{ otopq, ffi ffii qTPiGi5-drdr

Please complete all details and strike out the non-applicable fields/boxes.

fr&c E-{s-dI qrq : ilrrrd EfiI EftresName of Depository Participant: Nepal DP Limited (snqr / Branch):

srdrdr frfuq:Types ofAccount:

ffitG-s{sr

Ll qCIrralndividual

n fR eTrsr$q ffiNon Resident Nepalese

fernrffir ETfl qq{(Beneficial Owner Account No.)

E f{MForeigner

9 a o q q (t o o

ffitqrqName of Beneficial Owner

cr+I frfr (Dateof Birth) a..d. (8.s.) €.€. la.o.)

filq (eender) D gsq (Mate) E qeor (Female)

qT&q-dr (Nationatity) f,l ffi {Nepati) f] erq (other)

qtltfo6-fl qE{:Citizenship No:

cnff fu6rlssue District

qrt frftlssue Date

{r€l.Erft qq{ Passport No. qr$ ar€(Place of lssue qr$ frfr (tssue Date) I *nq lsfrri frfr(Expiry Date)

Cfq1lq-d Tr7pe5 ofu;I ftRTq ldentity Card

qfurqq* ldentification

=i.No.

qtt rr$ fto.rqlssuance Authority

Eilrt frfr lssue Date

tEffiIIt .f{ }qfqf, Correspondence Address:

YIE Country: SlsEf.Et Zone: fuerr, District:

m.ft.v./r.w1r..r.w.VDC/Municipality/Metrcpolitan

et6Tole:

trgl ;i.Ward No.:

qiE i.:Block No.:

tfrtEr){ =i.: (Telephone No.}: +fcrg,o ;f. (tzlobile No.):

Eqrffi t: FaxNo.: fto: {E-maiilD):

t?ff$ -&rn-qr: Permanent Address:

qqozone. fuor District: w'Ev./e.w.le.e.vr.VDC/Municipality/Metrcpolitan

dorole: qsr t Ward No.: e-O d": Block No.:

tfuw.t{ =i. : fielephone No.) : t'rer{d ;i. (Mobile No.)

S.qfffi t: Fax No.: S*o: {E-mailtD):;rfrro-dt er<sqrd Nea rest La nd ma rk:

tt

\JtFTq{ rTRqrrfir E-sgEs.EiI R-+qo1 p.1r;|s of Family Members

agr gerdl qrrT

Grand Father's Name:

5qr6l;Tl-cFather's Name:

OlrrlftFl ;ffq

Mother's Name:

qft, IrcffiI qrc

Spouse's Name:

ffiqrqSon's Name:

ofitffifp6 drfi-irl "rFIUnmarried Daughter's Name:

5erffir.nrDaughter-ln-Law's Name:

wgtr+1rr,r

Father-ln-Law's Name:

Eqrqa ft-q$rr

t{rOocrjpation

+sr tr sq-or$ tr srffiro/ffieE w.ddUqr€.s.S.dr. tl aEfift{Service Go/L PublidPrivate Sector NGO/NGO r egal Expert

trfuilErs tl qrclt tr GqFff tr fur tu{-d E gB,l E erqExpert Businessperson '' ShJdent Retired HouseWifu O*rers

qFIIrdI IT*TT

Types of Businxs

E vsr<cManuhcturing

tr +qrgdService Oriented

€terriri;rrTOrganization's Name

BIIl=TrAddress

qciDesignation

sTrPI$ ft-fiurFinancial Details

sTIdfCi frfl (SfiftF G-fl.I) /tncomeLimit(Annuat Detaits)

El E q,oo,ooo T[.rI E S. g,oo,ooq tfu S. ?,oo,ooo gupto Rs' 1,0o,0oo

From Rs. 1,oo,m1to Rs. 2,m,ooo

E 5,. ?,oo,ooq tfu s" !,oo.ooo gq f] s. tt,oo,ooo rril qIEFrom Rs. 2,OO,0O1to Rs. 5,0O,OO0 Abo/e Rs.

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freq lrffiS ffit srnrrT r+gdt qer6 sqrfuo sqqT | tr.Nrsi tr qrmgi

Standing lnstruction for the automatic transactions Evo Er,r"q,rtrrdl fr{$rr srE rr+A@untSbtemera.

trtF{o, tl srqrBo 3 wfro- Daily - Weekly - 15 dalrs

tr qrRroMonthly

Iidtrdr-dl B{tq 1am-ora-dt =.6'cr

q',) Guardian' Details (ln case of Minor

rTFT/eR Name/Sumame:

friqofuI iHF.rtI Retationship with appticant:

q?nqlY t II.TI conespondence Mdress:

IIIE Country: gf:Elo: bne

fuor:oistrict: efttdrr d. Telephone No.:

IDAIIiffi T. FaxNo.: dftrf{o {.: MobileNo.:

{QTrff +qr i. PANNo.:: t+6 E-rnailtD:

qle, q. rTr{rd{-+} E6,qr Tiqem deTr qri{r6iF EtdI ate} TiOr{ Tcq{E I

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ic aTrqffrq ffiE I tl[FI ForNonResidentNepatese

&tr6 trrffi roreien Addres

Irft {city) q-q lstate)

Q31tuuntry lffiq drg =i. NRNCodeNo"

t{t qrtrd ff*gq (Bank Acount Deraits)

+6 iqmrd frfuc fiypesof BankAccount) E e-r;rd ElIflI SavingAccount flzrd grar CunentAccount

*o gnr ;Icft (Bank Account Number)

dcrfd *o grcr q$dr ffiI TIIT (NameofBank)

+fi YlrqIoll;ffi (Nameof Branch)

f6r{\to} qfu vq$ frqwr (Nominee'sDetaits):

Nt 5q q\rdl €ffien sr td Tsdd srrerrqr ffiI ErRF-S +t qrqqT qgdt q,Td .lffiI Eo-Erft .r{ qrstln the event of my death or incapacity, thefollowing named nominee shall be entifled to the balance of my demat account.

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6-6Erfi rr#r qrq:

NameofNominee:

ftffiIrlqrrgl:Relationship:

crrrrfu6ilr/wdcrfr TT{Citizenship/Passport No.

Gilt dr$Place of lssue

s+rAge

qarqK tqrn,Gonespondence Address:

tI$ (Country): SlEli6f (Zone);

fuot loistria;' tfrttDtc d. ftetephone No.):

q9ffi d 1raxruo.;: +cl5d i. llobitemo.;:

TQIrfi +qr i. 1eeruuo.;: {*o (r-mainD):

She Map of the Account Holde/s Residence

qr Ytdt Ter.q-frl rrffin

Location Map

From main road street ...........the distance of the Residence is ..........meten (approximately)

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l/\lle shalt acceptto the terms and conditions relating to the agreement between Depository Participants and Beneficial Ownef prevalent act, regulations, byelaws

and any amendments on it. l/We hereby acknowledge that the above disclosed details are true. I further hereby consentto bome any legal actions in case anyfulse

disclosure of information related to me/us and the Depository Participants reserve right to close my account. All disputes are subject'to the jurisdiction of courts in

Kathmandu, Nepal.

Fiqqrqi qrq :

Name of Applicant:

EffiT€N:

Slgnature:

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6in,*'" qqt 6rdl qRrd c-drrr rd€rirrPlease use black ink

?712(ffi) Beneficial owner's copy

ffit qrelT;rRN:

Benefi cial Account Number:I a o q I \ o o

nf{N-qfofd fufl uf sha rehotder's Deta i ts

;IFI (Name)

effffiO ffiITeN Authorized signature

gfuffiI 1ft( (neceipt) qr+qq t (npflicationtrto.) ftfr ioate):

grfi-$ rErcn rell-d qrgrq gfufrtql I wereceivedaccountopeningtorm.

;ffi (Shareholder's Name)

fr&c vffidt qrrr: dur6 EfiI EfrB'Depository Participant! Name: Nepal DP Umited

Gi€EFI/Signature:

#fd qq/comparry's stamp:

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