ANNEXURE D
Participant’s Name, Address & DP Id
(pre-printed)
DEMATERIALISATION REQUEST FORM
DRN
(to be filled-in by the DP)
Serial No. (Pre Printed) Date :_______________
I/We request you to dematerialise the enclosed certificates into my/our account as per the details
given below:
Client Id
Sole/First Holder Name
Second Holder Name
Third Holder Name
Company Name
Type of Security Equity/Others (please specify)
Quantity to be Dematerialised
(in figures)
(in words)
Face Value
ISIN
(To be filled in by the DP)
I N
Details of Securities :
† Free Securities † Locked-in Securities
Folio No. Certificate Nos. Distinctive Nos. Quantity
From To From To
Total No. of Certificates : ______________
Details of Locked-in Securities:
Lock-in reason
Lock-in release date
(In case the space is found to be insufficient, an annexure containing the certificate details in the same format may be
attached. Please use separate form for free securities and locked-in securities)
Declaration
I/We hereby declare that the above mentioned securities are registered in my/our name. The
original certificates are hereby surrendered by me/us for dematerialisation. I/We also hereby
declare that the securities surrendered by me/us for dematerialisation are free from any lien or
charge or encumbrance and represents the bonafide securities of the company to the best of
my/our knowledge and belief.
Holder(s) Signature(s)
Sole/First Holder
Second Holder
Third Holder
Participant Authorisation
We have received the abovementioned securities for dematerialisation. The application form is
verified with the certificates surrendered for dematerialisation and we certify that the application
form is in accordance with the details mentioned in the enclosed certificates. It is also certified
that the holders of the securities have beneficiary account with us in the same name(s).
Name of the Executive :
Signature : Participant’s Stamp & Date
=====================================================================
Acknowledgement
Serial No. (pre-printed)
We hereby acknowledge the receipt of ________________ shares/units/bonds/debentures of
__________________________________________________ surrendered for dematerialisation
by Mr/Ms/M/s ____________________________________ having Client Id ______________.
Date : Participant’s Stamp & Signature