AB3616409_SRN_FORM_1748692673232

Form No. DIR-5 Form language

Application for surrender of Director
English Hindi
Identification Number
[Pursuant to section 153 of the
Companies Act, 2013 and rule 11 of the Companies
(Appointment and Qualification of Directors) Rules, 2014]
1748692673232

Refer instruction kit for filing the form

All fields marked in * are mandatory

Reason for Surrender

1 *Reason for surrender of DIN Photograph of the DIN holder

Having multiple DINs

DIN was obtained in a wrongful manner or fraudulent means

Death of concerned individual

Concerned individual is declared as a person of unsound mind by a

competent court

Concerned individual hs been adjudicated as insolvent

Concerned individual is/was not associated with any company/LLP and the DIN
has never been used for filing of any document with any authority (Attach a latest passport size
photograph by clicking on above box)

Retained DIN details

2 (a) *Whether DIN holder is retaining any DIN Yes No

(b) Mention the DIN to be retained 03620944

(Note: DIN mentioned aforesaid will be replaced with all the other DINs for which surrender application is filed by the user)

(c) Name of the DIN holder

(i) First Name MOHAMED REZA

(ii) Middle Name ALI ZAHIR

(iii) Last Name MIRZA

(d) Father’s Name

(i) First Name *****AHIR

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 (ii)Middle Name ***** HUSAIN

*****
(iii)Last Name

(e) Date of Birth (DD/MM/YYYY) 23/09/1990

(f) Income-tax permanent account number ATYPM1182C

Surrendered DIN details

3 *Specify the number of DIN(s) being surrendered by the applicant 1

Particulars of the DIN(s) being surrendered

S. No. DIN Name Father’s Name

(i) (ii) (iii) (iv)
*** ***** KASIM HUSAIN
1 10136966 MOHAMED REZA MIRZA
*****

Applicant’s Details

4 *Whether the application is being digitally signed by the holder of DIN himself Yes No

5 Particulars of the applicant

(a) Name

(b) Relation with DIN holder

(c) DIN of the applicant (if any)

(d) Income-tax PAN

(e) *Mobile number of the applicant (with Country code)

(f) *Email-ID of the applicant

Other Details

6 Other information, if any, which the applicant intends to submit with regard to this application

AFFIDAVIT AND APPLICATION FOR SURRENDER OF DIN IS ENCLOSED HEREWITH

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Attachments

(a) Proof of Identity of the applicant

(b) Proof of residence of the applicant

(c) Affidavit including declaration that retained DIN will be Affidavit for DIN
updated with all CIN/LLPIN association Surrender.pdf

(d) Copy of court order declaring DIN holder as

insolvent/unsound mind

(e) Copy of death certificate

(f) Optional attachment(s) - if any

Declaration

* I hereby declare that information and other particulars given in this form are true and correct
* I further declare that I have never been appointed as in any company/LLP and the DIN has never been used for filing of
any documents with any authority

*To be digitally signed by MIRZA Digitally signed by

MIRZA MOHAMED
MOHAME REZA

DIN1
D REZA
Date: 2025.05.31
19:45:51 +05'30'

03620944

*Name MOHAMED REZA ALI ZAHIR

*DIN/PAN 0*6*0*4*

Certificate by Practicing Professional

* I declare that I have been duly engaged for the purpose of certification of this form

* I have satisfied myself about the identity of the applicant based on perusal of the original of the attached document.
Note - In case where the applicant is residing outside India the particulars have to be verified from the documents duly attested by
the attesting authority as prescribed

*I have gone through the provisions of the Companies Act, 2013 and Rules thereunder for the subject matter of this form and
matters incidental thereto and I have verified the above particulars (including attachment(s)) from the original records maintained
by the applicant which is subject matter of this form and found them to be true, correct and complete and no information material
to this form has been suppressed

*I further certify that all the required attachments have been completely and legibly attached to this form and it is understood

*To be digitally signed by HASNAIN

Digitally signed by
HASNAIN
SAJJADHUSSAIN

DIN2 16196
SAJJADHUSS KALWANI
AIN KALWANI Date: 2025.05.31
17:33:05 +05'30'

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 Chartered accountant (in whole-time practice) or

Cost accountant (in whole-time practice) or

Company secretary (in whole-time practice)

*Whether associate or fellow

Associate Fellow

*Membership number

Certificate of practice number 1*1*6

Note: Attention is drawn to provisions of Section 448 and 449 which provide for punishment for false statement / certificate and
punishment for false evidence respectively.

For Office use only:

eForm Service request number (SRN) AB3616409

eForm filing date (DD/MM/YYYY) 31/05/2025

Digital signature of the authorizing officer

This eForm is hereby approved

This eForm is hereby rejected

Date of signing (DD/MM/YYYY)

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