SyndicateBank, Depository Services
2nd Floor, SyndicateBank Building, 26, Sir P M Road, Fort Mumbai - 400 001
Dematerialisation Request Form

Normal Dematerialization
Transmission-cum- Dematerialization

Transposition-cum-Dematerialization
(To be filled up by the Depository Participant)
DRN Date D D M M Y Y Y Y
DRF No. Date D D M M Y Y Y Y
(To be filled by the BO. Please fill all the details in BLOCK LETTERS in English. Fill up a separate DRF for Free securities and Locked – in securities.
In case of locked - in securities fill up a separate DRF for different lock-in reason / lock-in expiry dates.)
I / We request you to dematerialise the enclosed security certificate(s) registered in my / our name into my / our demat account.
DP ID 1 3 0 5 0 6 0 0 Client ID
Name of the Company
ISIN I N
(Quantity to be Dematerialized In Figures)
(In Words)
Number Of Certificates (in words)
Nature of Securities
Free Securities
Lock-in Securities
Lock-in reason
Lock in Expiry Date D D M M Y Y Y Y
Details of Securities:
Type of Security
Equity
Debentures
Bonds
Units

Other (Specify)
Face Value of Securities
From To From To From To
Folio No.
Certificate Numbers
Distinctive Numbers
Quantity
Attach an annexure (duly signed by account holder(s)) in the above format if the space is not sufficient.
The original certificates / documents are hereby surrendered by me / us for dematerialisation and the same are free from any lien or charge or
encumbrance and represent the bonafide securities of the Issuer Company to the best of my / our knowledge and belief.
First / Sole Holder Second Holder Third Holder
Name
Signature with DP
Signature with RTA
Phone No:
Participant Authorization (From DP to RTA)
We have received the above-mentioned securities bearing ISIN__________________ for Dematerialisation. The Application form is verified
with the Certificates/Documents surrendered for dematerialisation and we certify that the application form is in accordance with the details
mentioned in the enclosed certificates / documents. It is also certified that the Holder(s) of securities have a beneficiary account with us in the
same name(s) and order of name(s).
Depository Participant Seal and Signature
P.T.O.
2
Acknowledgement Receipt
DRF No. Date D D M M Y Y Y Y
DP ID 1 3 0 5 0 6 0 0 Client ID
First / Sole Holder Name
Second Joint Holder Name
Third Joint Holder Name
Name of the Company
Type of Security
Equity
Debentures
Bonds
Units

Other (Specify)
ISIN
No. of Securities (in figures)
No. of securities (in words)
No. of Certificates (in figures)
No. of Certificates (in words)
We hereby acknowledge the receipt of certificates / documents, in respect of the following securities for dematerialization subject to verification.
Depository Participant Seal and Signature
Instructions:
1. In case of transmission – cum – demat, a notarized copy of death certificate of the deceased holder, copy of the order of the court etc. to be
attached with DRF.
2. In case of transposition –cum –demat, a duly executed transposition request form to be attached with the DRF.