Schedule - I - Application for grant of certificate - Securities and Exchange Board of India (Intermediaries) Regulations, 2008

SCHEDULE I SECURITIES AND EXCHANGE BOARD OF INDIA (INTERMEDIARIES) REGULATIONS, 2008 [Regulation 3] FORM A Application for grant of certificate The information contained herein is updated as on: dd/mm/yy INSTRUCTIONS FOR FILLING UP FORM 1 Applicants must submit to the Board a completed application form together with appropriate supporting documents and applicable application fees. Supporting documents should be attested as true by a notary public. 2 This application form should be filled in accordance with the regulations. 3 Application for registration will be considered, only if it is complete in all respects. 4 All answers must be typed. 5 Information which needs to be supplied in more detail may be given on separate sheets which should be attached to the application form. 6 All signatures on the application must be original. 7 Every page of the form as well as every additional sheet must be initialed by the authorised signatory of the applicant. Part I 1. General details of the applicant and its affiliates: Management Compliance Matrix/Structure 1.1. Name of the applicant: 1.2. Address of the registered office, address for correspondence, telephone numbers, fax numbers, e-mail, website, name and telephone number of the contact person, address of branch office, if any: 1.3. Date and place of incorporation/establishment and registration number given by the Registrar of Companies or any other authority: 1.4. Legal status of the applicant and the law, under which it is incorporated, established or registered, if any including where the applicant is a listed entity, the details of the exchanges (whether in India or abroad) where the applicant is listed: 1.5. Brief description of the principal activity of the applicant: (along with copies of the constitutional documents of the applicant) 1.6. Year of commencement of such activities ( if applicable): 1.7. Shareholding pattern of the applicant (please set out the names of all such persons who hold whether directly or indirectly more than 5% of the shareholding or voting rights in the company): Name of the shareholder No. of shares [% of shareholding]/[% of voting rights] Where control over the applicant is exercised by a person by way of an agreement or arrangement, details and documentation in relation to such agreement or arrangement as the case may be. 1.8. Details of significant affiliates of the applicant operating in India or abroad and activities carried out by them including details as regards the legal status of each such affiliates and the law, under which it is incorporated, established or registered, if any Legal Status and details of registration Name Address Telephone no Fax No E-mail address Nature of interest of the applicant in the affiliate, if any Nature of interest of such affiliate in the applicant, if any 1.9. Details of registration / recognition of the applicant with the Board and with other regulatory authorities or with stock exchanges or self regulatory organization (whether in India or abroad): The Regulator/ SRO Details of registration Registration No. Period of validity 1.10. Details of registration / recognition of each affiliates of the applicant with the Board or with other regulatory authorities or with stock exchanges or self regulatory organizations (whether in India or abroad): The Regulator/ SRO Details of registration Registration No. Period of validity 1.11 Details of the Compliance Officer: 1.12 Details of principal officers Name Job Title Business Address Telephone no Fax No E-mail address 1.12 Details of principal officers: Name Of Person Responsibility Qualification / Experience 1.13 Details of the Key Management Personnel Name Of Person Responsibility Qualification / Experience 1.14 Details of any conviction or any declaration of insolvency/winding-up of the applicant. 1.15 Details of actions taken against the applicant or its associates by any regulatory authorities. Sr. No. Authority Description of alleged default Action taken Current status Explanation : For the purpose of this clause affiliate shall mean where the applicant is a company, its holding company and its subsidiaries and where the applicant is an individual his/her dependant relatives. 2. Details of arbitration/litigation which could have a material adverse effect on the functioning of the intermediary and investor complaints. 2.1 Complaints pending for over three months: S. No. Name of the complainant Date of receipt of complaint Short description of complaint Current status 2.2 Arbitration / litigation cases: Forum Name of the Petitioner Short description of issue Current stage of proceedings Details of interim orders passed Details of final award / order 3 Brief description of the group 3.1 Brief description of the group, if any, to which the applicant belongs. Please confirm the details of the company and the group, tracing them down to the individual persons in control. 4 Management Details: 4.1 Provide the following details of the directors / partners / trustees of the applicant as the case may be: Name Details of interest in the applicant Directorships in other entities Controlling interest in other entities 4.2 Names of Promoters of the Applicant should be provided. Part II 5. Financial Reporting and Disclosure (where the intermediary is active): 5.1 Audited balance sheets and profit and loss account statements for the past three years (including notes to accounts); 5.2 Net Worth of the applicant for the past three years; segment wise turnover of the applicant (where necessary) [for eg. where the applicant is a stock broker, then the segment wise turnover i.e. turnover under the cash segment, the derivative segment, the commodities segment etc. may be provided) 6. Details of the taxation authority: 6.1 Please provide details of the authority where the applicant is subject to taxation. 6.2 Permanent Account Number/Registration Number/Code given by tax authority (if any) of the applicant and its directors, as applicable:: 7. Details of promoters and management personnel 7.1 Provide address and contact details (including telephone numbers, email, fax etc.) of the applicant s promoters as specified in Clause 4.2 of Part I of the Form. 7.2 Provide details of address and contact details (including telephone numbers, email, fax etc.) of the applicant s management personnel as specified in Clause 4.1 of Part I of the Form. 7.3 Provide Director s Identification Number of the directors of the applicant 8.Details of any show cause notices received by the applicant from any regulatory authority. Sr. No. Date of Notice Details of alleged violation Current status 9.Undertaking and Declarations: We hereby represent, warrant and declare that: 1 The information supplied in the application, including the attachment sheets thereto, is complete, true and accurate in all respects; 2 We are in compliance with, and have adhered to and fulfilled, all the criteria and conditions applicable for grant of certificate; 3 We further undertake that we will immediately notify the Securities and Exchange Board of India of any change in the information provided in the application in the manner as set out under the regulations; 4 We further undertake that we shall comply with the provisions of the Securities and Exchange Board of India Act, 1992 and the rules, regulations, guidelines, notifications, circulars, and any other directions as may be passed by the Securities and Exchange Board of India from time to time, issued thereunder and applicable to us, and all other relevant laws including guidelines issued by the Reserve Bank of India and the Government of India. 5 We further undertake that as a condition of grant of certificate, we shall abide by such operational instructions/ directives as may be issued by Securities and Exchange Board of India from time to time under provisions of the Act or any other law for the time being in force. For and on behalf of (Name of the applicant) Name of the applicant Signature Name of signatory Position Date dd/mm/yyyy Notes: