Know Your Client (KYC)
Intermediary
Application Form (For Individuals Only) CDSL VENTURES LIMITED
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….Exploring New Horizons
Please fill the form in ENGLISH and in BLOCK letters
Fields marked * are mandatory Application Number:
+
Fields marked are pertaining to CKYC and mandatory only if processing CKYC
also Application Type*: New KYC Modification KYC
KYC Mode*: Please Tick (✓)
Normal EKYC OTP EKYC Biometric Online KYC Offline EKYC Digilocker
1. Identity Details (please refer guidelines overleaf)
PAN* Please enclose a duly attested copy of your PAN Card
____________________________
ASFPC0786J
Name* (same as ID proof) VINAYAK DAMODAR CHOUDHARY
Maiden Name+ (if any)
Fathers/Spouse’s Name* Damodar Mhatarba Choudhary
Date of Birth* 07-04-1977
Gender* Male Female Transgender
Marital Status* Single Married Recent passport size
Nationality* Indian Other Applicant Photo
Residential Status* Resident Individual Non Resident Indian
Please Tick (✓)
Foreign National Person of Indian Origin+
Cross Signature across photograph
(Passport mandatory for NRIs and Foreign Nationals. PIO selection is only for CKYC and not for KRA KYC.
Select NRI or Foreign National based on Nationality of the individual)
Proof of Identity (POI) submitted for PAN exempted cases (Please tick)
A — Aadhaar Card XXXX XXXX __ __ __ __
xxxxxxxx1341
(Expiry Date)
B — Passport Number
C — Voter ID Card
(Expiry Date)
D —Driving License
E —NREGA Job Card
F — NPR
Z —Others (any document notified by Central Government)
Identification Number
2. Address Details* (please refer guidelines overleaf)
A. Correspondence/ Local Address*
Line 1* damodar bhavan ganga nagar old sangvi
Line 2 makan hospital Pune City
Line3
City/Town/Village* Pune District+ Pune Pin Code* 411027
State* Maharashtra Country* India
Address Type* Residential/Business Residential Business Registered Office Unspecified
Applicant e-SIGN
75/1/2/7/A-1, PWD Colony, Old Sangvi, Pimpri Chinchwad, Pimpri-Chinchwad, Maharashtra 411027, India
73.8174613
18.5759152
1
B. Permanent residence address of applicant, if different from above A / Overseas Address* (Mandatory for NRI Applicant)
Line 1* damodar bhavan ganga nagar old sangvi
Line 2 makan hospital Pune City
Line3
City/ Pune Pune 411027
Town/Village* District+ Pin Code*
Maharashtra
State* Country* India
Address Type* Residential/Business Residential Business Registered Office Unspecified
Proof of Address* (attested copy of any 1 POA for correspondence and permanent address each to be submitted)
A — Aadhaar Card XXXX XXXX __ __ __ __
xxxxxxxx1341
B — Passport Number (Expiry Date)
C — Voter ID Card
(Expiry Date)
D —Driving License
E —NREGA Job Card
F — NPR Letter
Z—Others (any document notified by Central Government)
Identification Number
3. Contact Details (in CAPITAL)
Email ID*
[email protected] ________________________________________________________________________________________
Mobile No. * _____ ____________________________
9881214969
Tel (Off) _____ ____________________________ Tel (Res) _____ ____________________________
4. Applicant Declaration
I/We hereby declare that the KYC details furnished by me are true and correct to Applicant e-SIGN Applicant Wet Signature
the best of my/our knowledge and belief and I/we under-take 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/We are aware that I/We
may be held liable for it.
I/We hereby consent to receiving information from CVL KRA through SMS/Email on
the above registered number/Email address.
I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be
validated against Aadhaar details. I/We hereby consent to sharing my/our masked
Aadhaar card with readable QR code or my Aadhaar XML/Digilocker XML file, along
with passcode and as applicable, with KRA and other Intermediaries with whom I
have a business relationship for KYC purposes only.
06/08/2025
DATE: _________________________ (DD-MM-YYYY)
PLACE: _______________________________________
Pune
5. For Office Use Only
In-Person Verification (IPV) carried out by* Intermediary Details*
IPV Date Self certified document copies received (OVD)
Emp. Name True Copies of documents received (Attested)
AMC / Intermediary Name :
Emp. Code
Emp. Designation
Employee Signature and Stamp Institution Name and Stamp
2
PAN VERIFICATION RECORD
Permanent Account Number
ASFPC0786J
NAME VINAYAK DAMODAR CHOUDHARY
GENDER MALE
DATE OF BIRTH 07-04-1977
VERIFIED ON 06/08/2025 19:05:57
Digitally signed on
Date : 06/08/2025 19:05:57 IST
Note:
1. This PAN data is accessed using DigiLocker.
2. This digitally signed document is valid as per IT Act.
Powered by TCPDF (www.tcpdf.org)
DigiLocker verified e-Aadhaar
This document is generated from verified Aadhaar XML obtained From DigiLocker with due user consent and authentication
Document type e-Aadhaar generated from DigiLocker verified Aadhaar XML
2025-08-06 2025-08-06
Generation date Download date
19:05:59.171949 19:05:59.171965
Masked Aadhaar number xxxxxxxx1341
Name Vinayak Damodar Choudhary Photo
Date of Birth 07-04-1977
Gender Male
C/O, S/O, D/O Damodar Mhatarba Choudhary
damodar bhavan ganga nagar old sangvi
Address makan hospital Pune City Pune
Maharashtra 411027
Landmark makan hospital Locality old sangvi
City/District Pune
Pin code 411027 state Maharashtra
For Limited Circulation | CONFIDENTAL
Applicant Wet Signature Page (mandatory)
