311, III Floor, Apollo Trade Centre,Geeta Bhavan Square. Indore-452001(M.P.)

Email-Id :-


***As per prescribed by SEBI circular No. CIR/MIRSD/16/2011 dated 22th Aug.2011***

(I)Note:- All Fields Marked with (*) are Mandatory.

A. *IDENTITY DETAILS  (All Fields Are Mandatory)

Gender:Male   Female
Marital status:Single Married
Please affix your
recent passport
size photograph
and sign across it
Date of birth:   (DD/MM/YYYY)
PAN No.:
Unique Identity Number(UID)(Aadhaar):
Specify the proof of Identity submitted:

B. *ADDRESS DETAILS  (Address's is Mandatory)

Pin Code:


*Specify the proof of address submitted for correspondence address:

Check this box if Correspondence Address and Permanent Address are the same.
Pin Code:State:
*Specify the proof of address submitted for correspondence address:

Email id:    

Below 1 Lakh 1-5 Lakh 5-10 Lakh
10-25 Lakh Above 25 Lakh

Private Sector Public Sector Business Professional
Agriculturist Retired Housewife Student
Others(Please Specify):
Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP)
No Political Relation


I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

Name of the Applicant

Signature of the Applicant ___________________________________________



1. The Equicom respects and values the right to privacy of each and every individual. By becoming clients you have a promise from our side that we shall remain loyal to all our clients and non clients whose information resides with us. This privacy policy of TheEquicom applies to the currents clients as well as former clients.
2. Your information, whether public or private, will NOT be sold , rented, exchanged, transferred or given to any company or individual for any reason without your consent.
3. Your information will be used SOLELY for providing the servicesto you for which you have subscribed to us and not for any other purposes.
4. Your information given to us represents your identity with us. If any changes are brought in any of the fields of which you have provided us the information, You shell bring it to our notice by either calling usor sending an email to us.
5. By filling out this form you are agreeing the comply with and be bound by the following terms and conditions of use along with the terms and conditions posted on the website, which together with our privacy policy govern Th Equicom relationship with you in relation to the website.
6. By signing the form above, you agree to provide us your valid mobile number. Also by providing your mobile number, you provide us the consent to call you on the number provided by you and send SMS on your mobile number. You provide your consent for us to use your mobile numbers even if it is registered on the National 'DO Not Disturb' registry.
7. The Equicom as a merchant shall be under no liability whatsoever in respect of any loss or damage arising directly or indirectly out of the decline of authorisation for any Transaction, on Account of the Cardholder having exceeded the preset limit mutually agreed by us with our acquiring bank from time to time.
8. The Equicom is registered as a company incorporated in india with Corporate Identity Number as U74130MP2012PTC028985, SEBI Registration Number as INA000001639, and PAN Number as AAECT4400E.


Seal/Stamp of the intermediary & Signature
(or TheEquicom head office)


1. Fill out the form in its entirety and put signature on all the pages along with the supporting documents.
2. Email the complete form along with the required documents to Please note that your services can not be started before this form is received at The Equicom as per SEBI regulations