CLIENT ID :

FORM FOR NOMINATION / CANCELLATION OF NOMINATION
(To be filled in by individual applying singly or jointly)

I/We ________________________________ and ________________________________ the holders of beneficiary owner account bearing Client ID No.____________ held with M/s. Indian Overseas Bank, a NSDL Depository Participant bearing DP ID No. IN 302437 wish to “make a nomination / cancel the nomination dated __________ and do hereby “nominate / cancel the nomination made by me / us on the ______day of ______________the following person in whom all rights of transfer and / or amount payable in respect of securities held in the Depository by me / us in the said beneficiary owner account shall vest in the event of my / our death/ and consequently all rights and liabilities in respect of beneficiary ownership in the securities held by me / us in the said account shall vest in me/us.
(Strike out whichever is not applicable)
Photograph of
Nominee
Signature of nominee across Photograph
Photograph of
Guardian
(in case of minor)
Signature of Guardian Across Photograph
Name and Address of Nominee
Name : __________________________________________________
Address : __________________________________________________
__________________________________________________
__________________________________________________
Date of Birth : __________________________________________________
(to be furnished in case the nominee is a minor)
Signature of the Nominee : __________________________________________________
The nominee is a minor whose guardian is : ________________________________________________
Address of the guardian : __________________________________________________
: __________________________________________________
: __________________________________________________
Signature of the guardian : ___________________________________________________
(In case of guardian his photograph should be affixed) to be deleted if not applicable.
Beneficial Owner
1
2
Signature: _________________________________
Name : _________________________________
Address : _________________________________ ____________________________________
Date : _________________________________
Signature: _________________________________
Name : _________________________________
Address : _________________________________ ____________________________________
Date : _________________________________
Signature of two Witnesses:
1
2
Signature: _________________________________
Name : _________________________________
Address : _________________________________ ____________________________________
Date : _________________________________
Signature: _________________________________
Name : _________________________________
Address : _________________________________
_________________________________
Date : _________________________________