investment and insurance mf sip plus arn euin (1)

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Mutual funds common application form ARN49611 EUIN E053607 Mob. 9817040604

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  • 1.ICICI PRUDENTIAL SIP PLUS [Common Application for SIP Plus] Application No. Please readthe INSTRUCTIONS carefully. All thesections to be completed in BLOCKLETTERSinENGLISH withBLACK / BLUECOLOURED INK. FOR ANY ASSISTANCE OR FURTHER INFORMATION PLEASE CONTACT US ICICI Prudential Asset Management Company Limited 3rd Floor, Hallmark Business Plaza, Sant Dyaneshwar Marg, Bandra (East), Mumbai - 400 051. India SIGNATURE, STAMP & DATE TOLL FREE NUMBER 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL enquiry@icicipruamc.com WEBSITE www.icicipruamc.com Note: All future communications in connection with this application should be addressed to the nearest ICICI Prudential Mutual Fund Customer Service Centre, quoting full name of the first applicant, the application serial number, the name of the scheme, the amount invested, date and the place of the Customer Service Centre where application was lodged. Application No. I confirm that I am aFirst timeinvestoracrossMutualFunds. (Rs. 150 deductible as Transaction Charge and payable to the Distributor) I confirm that I am an existinginvestorinMutualFunds. (Rs. 100 deductible as Transaction Charge and payable to the Distributor) TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction XI and please tick () any one] In case the purchase / subscription amount is Rs. 10,000 or more and your Distributor has opted to receive Transaction Charges, the same are deductible as applicable from the purchase/subscription amount and payable to the Distributor. Units will be issued against the balance amount invested. Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors assessment of various factors including the service rendered by the distributor. BROKERCODE(ARN) SERIAL NUMBER, DATETIME OF RECEIPT FOR OFFICIAL USE ONLYSUB-BROKERCODE ARN- EmployeeUniqueIdentificationNo.(EUIN)** **I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an execution-only transaction without any interaction or advice by the employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if any, provided by the employee/relationship manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction. Please if you wish to receive Account statement / Annual Report/ Other statutory information via Post instead of Email * Mandatory information If left blank the application is liable to be rejected. Please refer to instruction no.IX MANDATORY 2 BANK ACCOUNT DETAILS OF FIRST APPLICANT (Please Refer to Instruction No. III) Mandatory information If left blank the application is liable to be rejected. Name of Bank AccountNumberAccountType BranchName 9DigitMICRcode 11DigitIFSCCode Please any of the frequencies to receive Account Statement through e-mail : Daily Weekly Monthly Quarterly Half Yearly Annually 1 APPLICANT(S) DETAILS (Please refer to Instruction No. II) Enclosed (Please ) Attested PAN Card KYCAcknowledgementLetter Date of Birth* Enclosed (Please) Attested PAN Card KYCAcknowledgementLetter Date of Birth Enclosed (Please) Attested PAN Card KYCAcknowledgementLetter Date of Birth D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y PAN* PAN* PAN* Sole/First Applicant Mr. Ms. M/s FIRST MIDDLE LAST Mr. Ms. FIRST MIDDLE LAST3rd Applicant Mr. Ms. FIRST MIDDLE LAST2nd Applicant MandatoryinformationIfleftblanktheapplicationisliabletoberejected. For PANKYC requirements, please refer to the instruction Nos. II(3)X BranchCity NRI/PIO ResidentIndividual Status of First Applicant [Please tick ()] CorrespondenceAddress(Pleaseprovidefulladdress)* HOUSE / FLAT NO. STREETADDRESS STREETADDRESS COUNTRY PIN CODE Overseas Address (Mandatory for NRI / FII Applicants) HOUSE / FLAT NO. STREETADDRESS STREETADDRESS PIN CODE Tel.(Res.) Occupation [Please tick ()] Professional Business Retired Housewife Service Student Others (Please specify) CITY / TOWN STATE COUNTRY CITY / TOWN STATE Single Joint Anyone or Survivor (Default option: Anyone or Survivor) Mode of holding [Please tick ()] Mobile FaxTel. (Off.) Email 3 INVESTMENTPAYMENT DETAILS (Refer Instruction No. IV) For PlansSub-options please see Key Scheme Features for the scheme specific details. SIPThrough ECS/Standing Instruction / Direct Debit PDCs Name of scheme ICICI PRUDENTIAL OptionSub option (Please the appropriate boxes only if applicable to the scheme in which you plan to invest) Retail/Regular Option InstitutionalOption Growth/Cumulative OR Dividend Reinvestment or Payout SIP Frequency* Monthly QuarterlySIPDate 7th 10th 15th 25th Dividend Frequencies Daily Weekly Fortnightly Monthly Quarterly Half Yearly NRENROSavingsCurrent FCNR Gender* Male Female [Please tick ()] 49611 E053607

2. Subsequent SIP Instalment Details Start Month/ SIP Plus Year Tenure PER CHEQUE`Amount InvestedFrom Cheque No. to Cheque No. No. of Cheques Drawn on BANK / BRANCH *Default SIP Frequency is Monthly. PDCs - Post Dated Cheques M M Y Y Y Y Applications with Third Party Cheques, prefunded instruments etc. and in circumstances as detailed in AMFI Circular No.135/BP/16/10-11 shall be processed in accordance with the said circular. Please read the instruction no. VI(e). Third Party Payment Declaration form is available on www.icicipruamc.com or at ICICI Prudential Mutual Fund branch offices. TheTrustee,ICICIPrudentialMutualFund, I/WehavereadandunderstoodtheSchemeInformationDocument/KeyInformationMemorandumoftheScheme(s).I/WeapplyfortheunitsoftheFundandagreetoabidebytheterms,conditions,rulesandregulationsof theschemeandotherstatutoryrequirementsofSEBI,AMFI,PreventionofMoneyLaunderingAct,2002andsuchotherregulationsasmaybeapplicablefromtimetotime.I/Weconfirmtohaveunderstoodtheinvestment objectives,investmentpattern,andriskfactorsapplicabletoPlans/OptionsundertheScheme(s). I/wehavenotreceivednorbeeninducedbyanyrebateorgifts,directlyorindirectly,inmakingthisinvestment.I/Wedeclare thattheamountinvestedintheSchemeisthroughlegitimatesourcesonlyandisnotdesignedforthepurposeofcontravention orevasionofanyAct,RegulationsoranyotherapplicablelawsenactedbytheGovernmentof IndiaoranyStatutoryAuthority.I/Weagreethatincasemy/ourinvestmentintheSchemeisequaltoormorethan25%ofthecorpusoftheplan,thenICICIPrudentialAssetManagementCo.Ltd.(the'AMC'),hasfullright torefundtheexcesstome/ustobringmy/ourinvestmentbelow25%.I/WeherebydeclarethatIam/wearenotUSPerson(s).I/WeherebydeclarethatI/wedonothaveanyexistingMicroSIPswhichtogetherwiththecurrent application will result in a total investments exceeding Rs.50,000 in a year. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to him for the different competingSchemesofvariousMutualFundsfromamongstwhichtheSchemeisbeingrecommendedtome/us.I/WeinterestedinreceivingpromotionalmaterialfromtheAMC viamail,SMS,telecall,etc. Ifyoudonot wishtoreceive,pleasecallontollfreeno.1800222999(MTNL/BSNL)or18002006666(Others). DECLARATION FOR AVAILING INSURANCE COVER I am informed about the arrangement between ICICI Prudential Mutual Fund and the Insurance Company and about the details of the Master Policy Document. I understand that I am eligible to avail cover under such arrangement; and hereby wish to avail the said insurance cover. SIGNATURE OF SOLE / FIRST APPLICANT SIGNATURE OFSECONDAPPLICANT SIGNATUREOFTHIRDAPPLICANT ACKNOWLEDGEMENT SLIP Please Retain this Slip ICICI PRUDENTIAL SIP PLUS TobefilledinbytheInvestor. Subject to realization of cheque and furnishing of Mandatory Information. Scheme FromCheque/DDNo. FromDate TOTAL AMOUNTICICI PRUDENTIAL ToCheque/DDNo. AMOUNTPERCHEQUE BANK AND BRANCH ` `SCHEMEANDOPTION M M Y YY Y Date of Birth is MANDATORY in case Nominee is a minor Nominee Guardian Nominees Address Date of Birth SIGNATURE OF NOMINEE / GUARDIAN, IF NOMINEE IS A MINOR D D M M Y YNAME OF NOMINEE MANDATORY, IF NOMINEE IS A MINOR HOUSE / FLAT NO STREET ADDRESS CITY / TOWN PIN CODE Relationshipwith the minor () Natural guardian Courtappointedguardian 5 INVESTOR(S) DECLARATIONSIGNATURE(S) Payment Details for First Cheque/DD B`DDCharges (if applicable) A + B`Amount Invested Mode of Payment Cheque DD Funds Transfer NEFT RTGS Cheque / DD Number D D M M Y YDate AmountPaid A` Account Number 55yrs YourCurrentAge yrs = yrs For more information ref. Instruction No. XII(5). (E.g. Your Current Age is 40 years, then your SIP Plus Tenure would be 55 years 40 years = 15 years.) 55yrs YourCurrentAge yrs = yrs For more information ref. Instruction No. XII(5). (E.g. Your Current Age is 40 years, then your SIP Plus Tenure would be 55 years 40 years = 15 years.) SIPPlusTenure Pleasenotethatthisnominationwillberegisteredforinsurancealso. Micro SIPs (Please ) Mandatory for Investment of equal to or less than ` 50,000/- per annum under SIP registration (Please refer instruction No. V(h)) Sole/First Applicant 2nd Applicant 3rd Applicant PHOTOIDENTIFICATIONDOCUMENTTYPE(MANDATORY)(INCASEPAN HASNOTBEENPROVIDED) PHOTOIDENTIFICATIONDOCUMENTTYPE(MANDATORY)(INCASEPAN HASNOTBEENPROVIDED) PHOTOIDENTIFICATIONDOCUMENTTYPE(MANDATORY)(INCASEPAN HASNOTBEENPROVIDED) I.D. CARD NUMBER / REFERENCE NUMBER I.D. CARD NUMBER / REFERENCE NUMBER I.D. CARD NUMBER / REFERENCE NUMBER AccountType NRENROSavingsCurrent FCNR Bank Name BankBranch City SIGNATURE OF SOLE / FIRST APPLICANT SIGNATURE OFSECONDAPPLICANT SIGNATUREOFTHIRDAPPLICANT 4 NOMINANOMINANOMINANOMINANOMINATION DETTION DETTION DETTION DETTION DETAILSAILSAILSAILSAILS (Mandatory)::::: For Multiple nominations, please use the separate form available on AMCs website www.icicipruamc.com or with its branch offices. (ReferinstructionVII) I/WeherebynominatetheundermentionedNomineetoreceivetheamountstomy/ourcreditineventofmy/ourdeath. I/We also understand that all payments and settlements made to such Nominee and signature of the Nominee acknowledgingreceiptthereo