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ffi lmperial Securities Company Pvt. Ltd. Email: [email protected] 3rfiS - 1r Annox - 12 (Rfrqq qo {n sqff6y (Pursant to Byelaw 20) ryfrffi qffi kur$ qlfrI ffi Frifiqil 6tqT Format of Account Openinq Form for lndividual Beneficlal Owner rFT.i.: 1 Form No.i 1 arqfw rqtffifir ilFr cr{ For Offlcal Use Only qr+fi Tlr{ : Application No.: frtr : Date : {*-d rq"< : Symbol No.: ffiI efdl tr{r: Beneficial Owner Account No-i 1 t o 1 i 1 o o ?m siikd q:npi F4-4-or <r*(( rt rfu r wrqil rn-6R i\qit kdRE s-ds ri it6rcr ffi q-6t ilfrAr{ asr r Please complete all details and strike out the non-applicable fields/boxes. ffiqs<Erotdrfr ; fd0fifrrcr Wtr-fl o-sfi gr. fu. Name of Depository Participant : ffirql / Brsnch) qrdr+i kkq: .-qftnrr-d Types ofAccount: U tndiuidual fr-rrrfr+i k{<ur - rR qrsr*q ffi U Non Resident Nepalese - frt{ff U Foreigner Msi c Name of Beneficial Owner r;q futT Date of Birth k,d. B. S. t.d A. D. Fst Gender rm" rr rrker U Femate <rftrdT Nationality tr ffi,, i-_r Srar Ll 6g1s1 {rrrfu+ilr i'Ei.( Citizenship No. qrt ftrfrr lssue District qrt futd lssue Date rrrqrff qql Passport No. qrft 6rd Place of lssue qrft futd lssue Date qr< sfrri futtr Expiry Date qfMF6fkq Types of ldentity Cad cft-qqq{ ;i. ldentification No. qrt q+ F{6rq lsst€nceAufrody qrt frfd lssue Date trrrqr< rr trrrqr : Consspondence Address: TE: Country : i{Eif l Zone : frar: District : *qr Tole : {gr i'.: Ward No.: q+ i.: Block No.: iffia t.: Telephone No qtsrsd;i.: Mobi16 No.: SqFRI {.i Fax No.i **e, E-mail lD : rn.F+.s. zc.gr. zc.q.YI. : Voci/Municipality/Met opohlan

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ffilmperial SecuritiesCompany Pvt. Ltd.Email: [email protected]

3rfiS - 1rAnnox - 12

(Rfrqq qo {n sqff6y(Pursant to Byelaw 20)

ryfrffi qffi kur$ qlfrI ffi Frifiqil 6tqTFormat of Account Openinq Form for lndividual Beneficlal Owner

rFT.i.: 1Form No.i 1

arqfw rqtffifir ilFr cr{For Offlcal Use Only

qr+fi Tlr{ :Application No.:

frtr :Date :

{*-d rq"< :Symbol No.:

ffiI efdl tr{r:Beneficial Owner Account No-i 1 t o 1 i 1 o o?m siikd q:npi F4-4-or
Iqrfi Brrmr :Permanent Address:

3-li[ :Zone :

lqr-rl :District:

rTT.F{.{. / n.qt. / c.n.cr. :VDC/Municipality/Metropolitan

2la :Toel :

tf€T i.:Ward No.:
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fu qrff+l k{flrBank Account Details

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