| Form ISR-4 |
| (see circular No.
SEBI/HO/MIRSD/MIRSD_RTAMB/P/CIR/2022/8 dated January 25, 2022 on Issuance of Securities in
dematerialized form in case of Investor Service Requests) |
| Request for issue of Duplicate Certificate and other
Service Requests |
| (for Securities - Shares / Debentures / Bonds, etc.,
held in physical form) |
| Date: |
| A. Mandatory Documents / details required for processing all service
request: |
| I / We are submitting the following documents / details and undertake to request
the Depository Participant to dematerialize my / our securities within 120 days from the
date of issuance of Letter of Confirmation, received from the RTA/Issuer Company (tick
✓as
relevant, refer to the instructions): |
| • Demat Account No. (If available):
|
| Provide Client Master List (CML) of your Demat Account from the Depository
Participant* |
| • Provide the following details, if they are not already available with the RTA (see
SEBI circular dated November 03, 2021 in this regard) |
| PAN |
|
| Specimen Signature |
|
| Nomination / Declaration to Opt-out |
|
| *(Your address, e-mail address, mobile number and bank details shall be updated in
your folio from the information available in your CML). You can authorize the RTA to
update the above details for all your folios. In this regard, please refer to and use Form ISR-1
in SEBI circular dated November 03, 2021. |
| B. I / We request you for the following (tick ✓ relevant box) |
|
