CHECK LIST FOR AUTHORISED PERSON REGISTRATION IN COMMODITY

FOR INDIVIDUAL / SOLE PROPRIETOR

FAN CODE : LOCATION : JODHPUR ZONE

FAN NAME :SHIV SHANKAR BHOOTRA
TEL. NO. : DATE OF RECEIPT :
RM NAME : ASHISH AGARWAL

SR. CHECKLISTS MCX NCDEX

NO.

1. Cheque for Authorised Person Registration Fees in favor of 1710 1140

“India Infoline Commodity Ltd” payable at Mumbai (Non
refundable).

For an amount calculated @ Rs 2850- for both segment ( 1

cheque required for all segments instead of separate cheques)

It must be deposited under AXIS Bank INIDA INFOLINE

COMMODITIES LTD A/c no.910020018689301

2. Agreements on Non Judicial Stamp Paper of

Rs.100/- signed & stamped of Individual /
Proprietor on each page
a) New MCX Agreement AP 6.doc √

b) Member & Authorised Person Agreement (NCDEX) √

Click here
c) Alliance Partner Agreement √

d) Marketing Associate Agreement Rs. 300/- Non √

judicial stamp paper.
e) IIFL-Empanelment-Form.pdf √

3. Following documents need to be attested by Chartered √

Accountant (C.A.) (with C.A. Stamp, Signature &
Membership No) - MCX AP – 3 Undertaking on the
letterhead of Authorized Person with details of
Individual / Proprietor with duly attested by CA
4. MCX AP – 4 Undertaking on the letterhead of √
Authorized Person
5. Annexure IV Undertaking req. with details of √
Individual / Proprietor

6. Following documents need to be self attested and In person

verification by B.D.M. on each Proofs
a) Copy of PAN Card √ √
 c) Proof of Office Address (on trade name in case of √ √
proprietor) – One of the following

 Landline Telephone Bill*

b) Copy Proof (Minimum 10th Passed
 ofElectricity
Education bill* √ √
Mark sheet or Passed Certificate)
 Bank pass book*
 Voters id
 Driving License#
 Passport #
 Bank Statement*
 Shop Establishment Certificate
 Ration Card
 Rent Agreement with Residence Address
proof
* Only the latest ( not more than 3 months old )

d) Proof of Residence Address – (Authorized Person √ √

should be citizen of India)

 Landline Telephone Bill*

 Electricity bill*
 Bank pass book*
 Voters id card
 Driving License #
 Passport #
 Bank Statement*
 Ration card
*Only the latest ( not more than 3 months old )

1. In case of minor name mismatch in any of √ √

documents or proofs, required Name Change
affidavit on Non Judicial Stamp Paper duly notarized
and in case of major mismatch Gazette certificate of
name change signed by person whose name differs
required certified by CA.

2. In case of relative name mismatch in any of √ √

documents or proofs, required Name Change
affidavit on minimum Rs.20 Stamp paper duly
notarized and in case of major mismatch Gazette
certificate of name change signed by person whose
name differs required certified by CA.

3. In case of Applicant is married women than marriage √ √

certificate Compulsory or copy of passport, Voter
Id & Ration Card showing husband's name (duly
attested by CA)
1 Online FAN Payout Form √

2 Cancel Cheque Required with Bank statement √

For Relationship Manager at local branch only

I ……………………………….. (Name) ……………. (Employee Code) hereby confirm that I have

checked the complete set of registration documents and all documents required per the checklist is
attached. I know the applicant for last… months/years personally and am financially sound and having
moral character and integrity

Name and Signature

AP-3

SHIV SHANKAR BHOOTRA

MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in

Sr.N Name Father’s Name Husban Date of PAN No Qualificati Residential Address Contac Email ID
o d’s Birth on t/Mobil
Name e No
1 SHIV CHAMPA LAL 17/07/ ACMPB6 HSC MAHESHWARI 98283 HARIINV@YAH
SHANKAR BHOOTRA 1965 173B 84183 O.CO.IN
BHOOTRA
KI GALI,
INSIDE
CHANDPOLE,
JODHPUR,
JODHPUR,
RAJASTHAN -
342001
DETAILS OF INDIVIDUAL __SHIV SHANKAR BHOOTRA_(APPLICANT AUTHORISED PERSON’S
NAME) AS ON ________________

NOTES:
$ All initials to be expanded (full name to be indicated)
* In case of Co-operative Society provide details of all the Members / Directors by whatever name
called, of the Managing Committee / Governing Body
** Only in case of married female applicants. In case if the applicant has not changed her name and
address post marriage an undertaking to be obtained from applicant(s) for no change in name and address
post marriage duly self-certified and the same to be confirmed by Member also.
Date:
Sign of the
applicant
Place:
***Signature of Individual/Partner/Director with Stamp of the Authorised Person
CERTIFICATE
This is to certify that the details of Individual/partner/director/ members of Managing Committee
/Governing Body/ Directors of co-operative society in ______________ and as given above,
based on my/ our scrutiny of the books of accounts, records and documents is true and correct to
the best of my/our knowledge and as per information provided to my/our satisfaction and signed before
me.
For (Name of Certifying Firm)
Name of the Partner/Proprietor
Chartered Accountant
Membership Number
Date:
Please paste self-attested photographs of the Individual duly signed across:

Across
Photo
Signature

For India Infoline Commodities Ltd

Director/Authorised Signatory
AP-4

Undertaking

SHIV SHANKAR BHOOTRA

MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in

I/We Mr./Ms./M/s. ___SHIV SHANKAR BHOOTRA______ (name of the applicant) had applied for
appointment as Authorised Person of the Exchange through member, M/s. India Infoline Commodities
Ltd. (name of the member). In this regard, I/We hereby confirm/undertake that:

1. I/We and our partners/directors have not been suspended / barred by any of the Stock /
Commodity Exchange for a period of more than six continuous calendar months.
2. I/We and our partners/directors have not been convicted for any offence in the past and
presently not under trial for any offence involving fraud and dishonesty.
3. I/We will deal directly with investors and not through any other authorised person on
appointment with exchange.
4. I/We and our directors/partners is/are neither an Authorised Person of any other member of
the Exchange and nor has/have applied for appointment as Authorised Person with any
 other member of the Exchange.
5. I /We or any of our director/partner is not a member of the Exchange or director/partner of
any other member / authorised person of the Exchange.
6. I /We ensure that we shall not receive or pay any money or commodities in own name or
account and all receipts/payments of commodities and funds shall be in Member’s name or
account,
7. In case of change, in partners/ directors, change in shareholding/sharing pattern, we shall
intimate the Member with the details of the proposed change at least 45 days in advance in
the format prescribed by the Exchange. (format as given in AP-3/5a/5b)
8. In case of change in status and /or constitution, we shall intimate the Member with the
details of proposed change and all the documents at least 45 days in advance in the formats
prescribed by the Exchange.

I/We declare that the information given above is true and any misstatement or misrepresentation or
suppression of facts in connection with the above undertaking may entail rejection of our application
for / cancellation of Authorised Person at any time.

Date: ______________

Place: ______________ _________________________________

** Signature, Name & Seal

** Should be signed by Individual/ All partners / All Directors of the proposed Authorised Person.

ANNEXURE IV
to circular No. NCDEX/COMPLIANCE-008/2010/223 dated August 28, 2010

Details of the Individual ___SHIV SHANKAR BHOOTRA__

(Applicant Authorised Person)

No Name Father’s Date of Pan No. Qualificati Residential Address Contact No. Signature
Name Birth on
SHIV CHAMPA 17/07/1 ACMPB61 HSC MAHESHWARI KI 9828384183
SHANKAR LAL 965 73B GALI, INSIDE
BHOOTRA BHOOTRA
CHANDPOLE,
JODHPUR,
JODHPUR,
RAJASTHAN -
342001

Photographs of the Individual of ____________________ ___________________________ (Applicant

Authorised Person)

Please paste self attested photographs of the Individual duly signed across:
Across Photo
signature

Confirmed

(Name & Signature of the Member)

For India Infoline Commodities Ltd.

Director/ Authorised Signatory

SHIV SHANKAR BHOOTRA

MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in

To,
India Infoline Commodities Limited
IIFL House, Sun Infotech Park,
Road No. 16V, Plot No. B-23,
MIDC, Thane Industrial Area,
Wagle Estate,
Thane - 400604.

Sub: Request for ONLINE TRANSFER of payout.

Dear Sir,
With reference to the above subject, you are requested to transfer my monthly payout to below
mentioned bank account
FAN Code
FAN Name
Fan Address

Pin code: State:

Bank Details:
Beneficiary Name
(Name of A\C
Holder)
Bank Name
Bank Account
Number
Bank Account Type Savings Current
Bank Branch Address

Pin code: State:

MICR Code *
IFSC Code **

* 9 Digit Code number of the Bank & branch appearing on the cheque issued by the bank
** This code is printed on the cheque and if the same is not printed on the cheque it should be
obtained from the respective bank of the account holder. Also if the FAN is having an ‘at par’ account
with any bank, the IFSC code mentioned on the cheque would be the common IFSC code of the Bank;
in such cases the IFSC code of the respective local Branch needs to be obtained from the Bank.

ENCL: 1) Cancelled cheque leaf

2) Latest account statement.

Thanking You,
Authorized Signatories
Name…………………

Letter for MCX and NCDEX Segment

Details of Mr/ Ms. _SHIV SHANKAR BHOOTRA as on dd/mm/yyyy

Name: Mr SHIV SHANKAR BHOOTRA

PAN: ACMPB6173B

Birth Date: 17/07/1965

Residence Address: MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, JODHPUR,

RAJASTHAN - 342001
Office address: MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, JODHPUR,
RAJASTHAN - 342001

Contact No.: 9828384183

Bank Account No.: 01421600000669

Bank Name: HDFC BANK

Date:

Place: JODHPUR Signature: - _________________________

Bank Verification
This is to certify that Mr. / Ms.SHIV SHANKAR BHOOTRA maintain the aforesaid bank account with our

Bank since ___________ (mention date) and we confirm that his / her signature given above is as per

our records. This certificate is issued at the specific request of our customer.

Date:
Place:
Recent Photograph of Customer Name & Signature of Bank Official.

Authorization No. of Bank Official:

Bank Stamp

Member Confirmation

We also confirm the signature of above applicant is correct

Signature of Members Authorized Signatory - _______________________

Name -

SHIV SHANKAR BHOOTRA

MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in

Undertaking

Subject: Not to deal with Trading Member (TM) other than TM/Broker where registered
I / We ___SHIV SHANKAR BHOOTRA an individual/ company/ firm having residence address/
registered office at_MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, JODHPUR,
RAJASTHAN - 342001 I/we hereby undertake that I/we are not dealing any proprietary trading or for
trading on behalf of clients other than India Infoline Ltd where I/we are registered.

If at any time it found violation of above provision then, then SEBI/Exchange can initiate necessary
disciplinary action against me / us as per provision.

Date: Authorised Person name:

Place:

Signature:

(Stamp in case of Proprietor)