scripbox Investor Application Form

scripbox.com ARN-84967
PLEASE PRINT, SIGN AND SEND THIS FORM TO THE ADDRESS AT THE BOTTOM OF THE PAGE
INVESTOR ID 145636

Email tanudubey20@gmail.com

Application No. 145636A02

INVESTOR DETAILS
Investor Name
Tanu Dubey

Date of birth
Mar 30, 1990

Minor
NO

Guardian Name

Correspondence Address
91 Dalchand, Pilibhit, 262001, Uttar Pradesh

PAN
AXKPD5559L

Nationality
India

Resident Status
Resident Indian
(Individual)

Relationship

Guardian PAN

Overseas Address

Gross Annual Income

5-10 Lac

Occupation
Private Sector Service

Politically Exposed Person

No

Related to a Politically Exposed Person

No

Telephone
+91 8056004101

BANK DETAILS
Bank Name
HDFC Bank Ltd
NOMINEE DETAILS
Nominee Name
Anunay Dubey

Branch Name
Asansol

Account No.
03241140010571

Account Type
Savings Account

IFSC Code
HDFC0000324

Nomination not required

Relationship
Brother

Date of birth
Jul 10, 1981

Address
91 Dalchand , Pilibhit, Uttar Pradesh, 262001
DECLARATIONS
I confirm that the above details are true and correct. I am responsible for keeping the above information current and accurate. I confirm
that I am 18 years of age or older and, where I am acting as a Guardian, I have the necessary authority to execute this document and
operate the investment account on behalf of the minor.
I have understood, and agree to abide by the terms of the Investment Services Agreement appended to this Application Form. (Page 2)
I authorise Scripbox.com India Private Limited ("Scripbox") and/or its authorised service provider(s) to
- execute the ECS/NACH/Direct Debit mandate enclosed with this application form (Page 3), subsequent ECS/Direct debit instructions
related to my investments and electronic money transfer instructions through online payment gateway(s).
- carry out all mutual fund subscription/ redemption/ non-financial instructions ("Instructions") which I provide through the website
https://scripbox.com ("Website") using the Email and Password then associated with my Investment Account ("Login Credentials").
- communicate with the AMC on my behalf for financial and non-financial transactions and to receive details of my investment from the
AMC.

Date of online application

Sep 1, 2015

Place
Pilibhit

Sign here

...........................................
Tanu Dubey
Documents Checklist
Documents for Tanu Dubey
Application Form (Signed on both pages)
Bank Mandate (Signed)
Cheque Leaf (Cancelled Original)
PAN Card Copy (Signed Photocopy)
scripbox.com India Private Limited
#128/8, #32, Golden Tower, 7th Floor, Kodihalli, Old Airport Road, Bangalore-560017, India.
To have your form collected, please call 1800-200-1265

INVESTMENT SERVICES AGREEMENT

A. I acknowledge that:
1. I have applied for an Investment Account after understanding the nature and scope of services ("Services") provided by Scripbox.
2. This document is a legal contract between Scripbox and me ("Agreement").
3. The operation of my investment account and the execution of Instructions are subject to this Agreement, and the Offer Documents* of the respective
Asset Management Company ("AMC").
4. My identity on the Website is authenticated by the use of my Login Credentials. Scripbox will consider Instructions authenticated by my Login
Credentials to have originated from me.
5. I have the right to transact directly with the AMC even in respect of the investments made through Scripbox.
B. Under this Agreement, Scripbox's obligations are to provide Services as below:
1. Offer scientifically selected mutual fund schemes.
2. Facilitate subscription and redemption of mutual fund units by transmitting my money and Instructions to the appropriate AMC, as per my Instructions.
3. Securely and confidentially maintain a record of my personal information and my financial transactions.
4. Promptly & efficiently respond to my queries relating to my online investment account.
C. Under this Agreement, my obligations are to:
1. Ensure that the money I invest is from my bank account (primary holder's bank account in case of Investment Account held jointly), is from legitimate
sources and is remitted through approved banking channels.
2. Keep my Login Credentials safe and secret. Promptly change my Login Credentials and inform Scripbox of any actual or suspected unauthorised use of
my Login Credentials.
3. Make an informed investment decision by reading the Offer Documents* of the mutual fund schemes that I am investing in.
4. Seek independent financial planning, legal, accounting, tax or other professional advice before investing or withdrawing.
D. I further acknowledge and agree to the following:
1. I am aware that Scripbox is an AMFI registered distributor of mutual funds and receives commissions from AMCs, details of which are available on the
Website.
2. My Investment Account will be activated after Scripbox verifies my personal information in accordance with the Know Your Client ("KYC") guidelines
issued by the Securities and Exchange Board of India ("SEBI").
3. Scripbox does not, and is not obliged to, offer all mutual fund schemes for investment. By limiting the number of schemes on the Website, Scripbox does
not make any representation as to the quality, bona fides or nature of any AMC or mutual fund scheme, or any other representation, warranty or
guaranty, express or implied.
4. For investments using ECS/NACH/ Direct Debit, Scripbox will first submit the fund transfer instruction(s) to my bank. My request for subscription will be
sent to the AMC only after receiving confirmation of successful money transfer to the AMC's account. Consequently, there may be a lag between the
date of debit to my account and date Scripbox submits my request to the AMC.
5. Subject to point no. D.4, my Instructions will be processed the same day if received before the cut-off time(s) specified by Scripbox. Else, my Instructions
will be processed on the next business day. Scripbox may specify cut-off time(s) earlier than the time(s) specified by the AMC/ SEBI.
6. Scripbox will forward my Instructions to the AMC electronically and the AMC will process the transactions on the basis of such electronic instructions.
AMCs are not obliged to accept my application for subscription to units of their mutual fund schemes in part or in full.
7. For Investment Accounts held jointly, the mutual fund folios maintained by the concerned AMC will also be held jointly and all the individuals will have
the same authority to operate those folios (Any or Survivor).
8. The data and information provided on the Website does not constitute advice and shall not be relied upon by me while making investment decisions.
9. In case I violate this agreement, or any local or international laws, Scripbox may, at any time and at its sole discretion, terminate my Investment Account
and/or prevent me from accessing the Website and/or Services at any time and at its sole discretion.
10. Scripbox may modify these terms at any time by informing me. My continued use of the Services will imply my acceptance of the changes.
E. I will not dispute and/or hold Scripbox responsible for:
1. Any act that is not an obligation of Scripbox in this Agreement.
2. Any disclosures made by Scripbox to any statutory body under any law.
3. Any loss, notional or otherwise, incurred because of
a. delays either at the Bank, Registrar and Transfer Agency or AMC.
b. rejection of my instructions by the Bank, Registrar and Transfer Agency or AMC.
c. processing of Instructions authenticated by my Login Credentials
d. non-availability or non-accessibility of the Website, telephone(s), or office(s) of Scripbox in case of circumstances beyond Scripbox's control.
F. Governing laws
The laws of India govern this Agreement. All disputes are subject, firstly, to mediation, and then by Arbitration by a sole arbitrator appointed by Scripbox.
The venue of arbitration will be Bangalore.
G. SEBI Caution
Mutual Fund investments are subject to market risks, read all scheme-related documents carefully.
* Offer Documents: Collective term for Offer Document, Scheme Information Document, Statement of Additional Information, Key Information Memorandum,
issued by the Asset Management Company that manages the mutual fund.

scripbox.com India Private Limited

#128/8, #32, Golden Tower, 7th Floor, Kodihalli, Old Airport Road, Bangalore-560017,
India.
To have your form collected, please call 1800-200-1265

Sign here

...................................................
Tanu Dubey

BANK MANDATE
This Mandate is required to automate the process of investing for you.
It is an authorisation from you to your bank to transfer funds from your bank account to the bank account of the appropriate Mutual Fund
Company.

scripbox.com India Private Limited

ONE TIME BANK MANDATE

(NACH / ECS / Direct Debit Mandate Form)
(Applicable for Lumpsum Additional Purchases as well as SIP Registration)

Tick ( )
create
Modify
Cancel

UMRN

Date

Sponsor Bank Code

I/We hereby authorize scripbox.com India Pvt ltd to debit (tick )

Bank A/c no:

SB

CA

CC

SB-NRE

Qtly

H-Yrly

Yrly

50000
As & when presented

Reference 1: 145636

DEBIT TYPE

Fixed Amount

Maximum Amount

Email ID: tanudubey20@gmail.com

Reference 2:
PERIOD
From : 0 1 0 9 2 0 1 5
To :
OR :
Until Cancelled

Other

IFSC H D F C 0 0 0 0 3 2 4 or MICR 7 1 3 2 4 0 0 0 3

an amount of Rupees FIFTY THOUSAND ONLY

Mtly

SB-NRO

0 3 2 4 1 1 4 0 0 1 0 5 7 1

With Bank HDFC Bank Ltd

FREQUENCY:

01092015

Utility Code

Phone No: 918056004101

1

2
Signature of Account Holder

1 Tanu Dubey
Name as in bank records

3
Signature of Account Holder

Signature of Account Holder

3
Name as in bank records

Name as in bank records

FEW COMMON QUESTIONS RELATING TO THE BANK MANDATE:

I only want to invest Rs 20,000. Why is the amount 50000 in the mandate above?
This is the maximum amount and not the specific investment you are planning at this time. This mechanism allows you to make multiple
investments (either lump sum or SIP) without registering a separate bank mandate for each investment.
For example: You may want to make a Rs 50,000/- investment when you get your bonus or increase the amount of SIP as your salary increases.
If we have a fixed amount mandate, you will need to print, sign and send another mandate to us with every new investment. The upper limit of
50000 has been decided based on the investing behaviour of a typical investor.
The amount transferred from your bank account is based on the amount you choose to invest.
When will money be transferred?
Money will be transferred as and when you place an investment instruction online by logging into Scripbox.com. This completely depends on you.
Sending your mandate now will only set up the account and make it ready for when you want to invest.
Does the money go to the bank account of Scripbox?
No. The money does not go to the bank account of Scripbox. It goes from your bank account to the mutual fund company via an RBI approved
payment service provider.
This is also as per SEBI regulations.
Can I revoke this mandate when I want?
Yes. You can do so at any time by contacting your bank directly.

If you have any other questions, please call us on 1800-200-1265

This page has been intentionally left blank.

Know Your Client (KYC)

Application Form (For Individuals Only)

Application No :

Please ll in E N G L I S H and in BLOCK L E T T E RS with black ink

A. Identity Details (please see guidelines overleaf )

1. Name of Applicant ( As appearing in supporting identication document).
Name T A N U
D U B E Y
Father's/Spouse Name

Male

2. G ender

Single

B.Marital status

Y
C. Date of Birth

Married

Other Please Specify

4. Status Please tick ( )

5. PAN

Female

Indian

3. Nationality

Resident Individual
P

Non Resident
9

Foriegn National ( Passport Copy Mandatory for NR Is & Foriegn Nationals)

Please enclose a duly attested copy of your PA N Card

Unique Identication Number ( U I D ) /Aadhaar, if any:

6. P roof of Identity submitted for PAN exempt cases

UID ( Aadhaar)

Passport

Paste photo and sign across

Please tick ( )

Voter ID

Driving Licence

( Please see guidelines overleaf

Others

B. Address Details (please see guidelines overleaf )

1. Address for Correspondence
9

C ity/Town/Village

State

P
T

I
A

L
R

B
P

H
R

I
A

T
D

P in C ode

C ountry

2. Contact Details
Tel. (Off. )
Mobile
E - MailId.

( ISD)
( ISD)

( STD)
( STD)

( ISD)
( ISD)

Tel. (Res. )

8
D

0
U

5
B

6
E

0
Y

0
2

4
0

1 0
@ G

1
M

Fax

( STD)
( STD)

3. Proof of address to be provided by Applicant. Please submit A NY ONE of the following valid documents & tick () against the document attached.
Passport

Ration Card

Registered Lease/Sale Agreement of Residence

*Latest Telephone Bill (only Land Line)

*Latest Electricity Bill

Driving License

Voter Identity Card

Others ( Please Specify)

*Latest Gas Bill

d

* Not more than 3 Months old. Validity/Expiry date of proof of address submitted

*Latest Bank A/c Statement/Passbook

y

4. Permanent Address of Resident Applicant if different from above B1 OR Overseas Address ( Mandatory) for Non-Resident Applicant

C ity/Town/Village

P in C ode

State

C ountry

5. Proof of address to be provided by Applicant. Please submit A NY ONE of the following valid documents & tick () against the document attached.
Passport

Ration Card

Registered Lease/Sale Agreement of Residence

*Latest Telephone Bill (only Land Line)

*Latest Electricity Bill

Driving License

Voter Identity Card

Others ( Please Specify)

*Latest Gas Bill

d

* Not more than 3 Months old. Validity/Expiry date of proof of address submitted

*Latest Bank A/c Statement/Passbook

y

6. Any other information:

DECLARATION

SIGNATURE OF APPLICANT

I hereby declare that the details furnished above are true and correct to the best of my/our 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/we are aware that I/we may be held liable for it.
Place: Pilibhit

Date: Sep 1, 2015

FOR OFFICE USE ONLY

A MC/Intermediary name OR code
( Originals Veried) Self Certied Document copies received
( Attested) True copies of documents received
Main Intermediary

Seal/Stamp of the intermediary should contain

Staff Name
Designation
Name of the Organization
Signature
Date

IPV Done

on d

/ m m

Seal/Stamp of the intermediary should contain

Staff Name
Designation
Name of the Organization
Signature
Date

INSTRUCTIONS / CHECK LIST FOR FILLING KYC FORM

A. IMPORTA N T POIN TS:
1. Self attested copy of PAN card is mandatory for all clients.
2. Copies of all the documents submitted by the applicant should be selfattested and accompanied by originals for verication. In case the
original of any document is not produced for verication, then the
copies should be properly attested by entities authorized for attesting
the documents, as per the below mentioned list.
3. If any proof of identity or address is in a foreign language, then
translation into English is required.
4. Name & address of the applicant mentioned on the KYC form, should
match with the documentary proof submitted.
5. If correspondence & permanent address are different, then proofs for
both have to be submitted.
6. Sole proprietor must make the application in his individual name &
capacity.
7. For non-residents and foreign nationals, (allowed to trade subject to
RBI and FE MA guidelines), copy of passport/PIOCard/OCICard and
overseas address proof is mandatory.
8. For foreign entities, CIN is optional; and in the absence of DIN no. for
the directors, their passport copy should be given.
9. In case of Merchant Navy NRI's, Mariner's declaration or certied copy
of CDC ( Continuous Discharge Certicate) is to be submitted.
10. For opening an account with Depository participant or Mutual Fund,
for a minor, photocopy of the School Leaving Certicate/Mark sheet
issued by Higher Secondary Board/Passport of Minor/Birth Certicate
must be provided.
11. Politically Exposed Persons ( PE P ) are dened as individuals who are or
have been entrusted with prominent public functions in a foreign
country, e.g., Heads of States or of Governments, senior politicians,
senior Government/judicial/military ofcers, senior executives of state
owned corporations, important political party ofcials, etc.

B. Proof of Identity( POI): List of documents admissible as Proof of

Identity:
1. PAN card with photograph. This is a mandatory requirement for all
applicants except those who are specically exempt from obtaining
PAN (listed in Section D ).
2. Unique Identication Number ( UID ) ( Aadhaar ) / Passport / Voter ID
card / Driving license.
3. Identity card/ document with applicant's Photo, issued by any of the
following: Central/State Government and its Departments,
Statutory/Regulatory Authorities, Public Sector Undertakings,
Scheduled Commercial Banks, Public Financial Institutions, Colleges
afliated to Universities, Professional Bodies such as ICAI, ICW AI, ICS I,
Bar Council etc., to their Members; and Credit cards/Debit cards issued
by Banks.

C. Proof of Address (POA ): List of documents admissible as Proof of

Address: (*Documents having an expiry date should be valid on the
date of submission.)
1. Passport/Voters Identity Card/Ration Card/Registered Lease or Sale

Agreement of Residence/Driving License/Flat Maintenance

bill/Insurance Copy.
2. Utility bills like Telephone Bill (only land line), Electricity bill or Gas
bill Not more than 3 months old.
3. Bank Account Statement/Passbook - Not more than 3 months old.
4. Self-declaration by High Court and Supreme Court judges, giving the
new address in respect of their own accounts.
5. Proof of address issued by any of the following: Bank Managers of
Scheduled Commercial Banks/Scheduled Co - Operative
Bank/Multinational Foreign Banks/Gazetted Ofcer/Notary
public/Elected representatives to the Legislative
Assembly/Parliament/Documents issued by any Govt. or Statutory
Authority.
6. Identity card/document with address, issued by any of the following:
Central/State Government and its Departments, Statutory/Regulatory
Authorities, Public Sector Undertakings, Scheduled Commercial Banks,
Public Financial Institutions, Colleges afliated to Universities and
Professional Bodies such as ICAI, ICW AI, ICS I, Bar Council etc.,to their
Members.
7. For FII/sub account, Power of Attorney given by FII/sub -account to
the Custodians (which are duly notarized and/or apostiled or
consularised ) that gives the registered address should be taken.
8. The proof of address in the name of the spouse may be accepted.

D. Exemptions/clarications to PA N
(*Sufcient documentary evidence in support of such claims to be
collected.)
1. In case of transactions under taken on behalf of Central Government
and/or State Government and by ofcials appointed by Courts e.g.
Ofcial liquidator, Court receiver etc.
2. Investors residing in the state of Sikkim.
3. UN entities/multilateral agencies exempt from paying taxes/ling tax
returns in India.
4. S IP of Mutual Funds upto Rs50,000/-p.a.
5. In case of institutional clients, namely, FIIs, Mfs, VCFs, FVCIs,
Scheduled Commercial Banks, Multilateral and Bilateral Development
Financial Institutions, State Industrial Development Corporations,
Insurance Companies registered with IRDA and Public Financial
Institution as dened under section 4A of the Companies Act, 1956,
Custodians shall verify the PAN card details with the original PAN card
and provide duly certied copies of such veried PAN details to the
intermediary.

E. List of people authorized to attest the documents:

1. Notary Public, Gazetted Ofcer, Manager of a Scheduled
Commercial/Co -operative Bank or Multinational Foreign Banks ( Name,
Designation & Seal should be afxed on the copy).
2. In case of NRIs, authorized ofcials of overseas branches of Scheduled
Commercial Banks registered in India, Notary Public, Court Magistrate,
Judge, Indian Embassy/Consulate General in the country where the
client resides are permitted to attest the documents.

Please Submit the KY C Documents on A4 Size Paper Only.