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ANNEXURE-1I |
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PERFORMA 1 . Full Name |
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| 2. If You Have Changed Your Name, State Previous Name and Reasons for Change | ||||||||
| 3. Parents and Spouse's Names | ||||||||
| Father's Name: | ||||||||
| Mother's Name: | ||||||||
| Spouse's Name: | ||||||||
| 4. Date & Place of Birth | ||||||||
| 5. Religion | ||||||||
| 6. N.l.C. Number: Old / New | ||||||||
| 7.N.T.N. | ||||||||
| 8. Education | ||||||||
| 9. Relationship with other Sponsor Directors | ||||||||
| 10. Status of Directorship (shareholder or nominee) | ||||||||
| 1 1 . Subscribed Amount | ||||||||
| 12. Personal Net Worth (Certified copy of Wealth Statement may be enclosed) | ||||||||
| 13. Occupation / Profession / Trade | ||||||||
| 14. Present Designation. Department and official Address | ||||||||
| 15. Telephone Numbers: Res. Off: Mobile: | ||||||||
| 16. Appointments Held During the Last Five Years (With Dates): | ||||||||
| 17. List of Companies / firms and their bankers in which sponsor directors and their family | ||||||||
| members viz. spouses, children an parents serve (d) as directors, chief executive, partner, | ||||||||
| proprietor or major shareholders holding 5% or more shares as per following format: | ||||||||
| Name of | Occupation/ | National | NIC & | Name of | Name of the Financial | |||
| the | Profession/ | Tax No. | Passport | Associated | Institution along with | |||
| Sponsors | Trade | No. | Company / | the name of the | ||||
| Director an | Firm position | branch (account | ||||||
| his / her | held & % of | number) with which | ||||||
| family | Shareholding | firms / companies (as | ||||||
| Members | per column 5) have | |||||||
| dealings with: | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | |||
| National | Nature of | Asset Base | Dividend | |||||
| Tax | Business | as reflected | declare in | |||||
| Number of | in the latest | the | ||||||
| the | Audited | immediately | ||||||
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Corporate Bodies. |
Accounts of the |
preceding three years |
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| Corporate | ||||||||
| Bodies | ||||||||
| 7 | 8 | 9 | 10 | |||||
| 18. Declaration certificate pronouncing integrity, honesty, reputation and track record of the | ||||||||
| director as per guidelines given in Annexure -II | ||||||||
| 19. Present Residential Address: | ||||||||
| 20. Permanent Residential Address: | ||||||||
| 21. Names & Addresses of Three Respectable Persons (Not Relatives) Who Have Been Closely | ||||||||
| Acquainted with You during last five years | ||||||||
Signature
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