NOMINATION FORM (Signature of all Account Holders must be obtained on this form)	[Strike out what is not applicable]
I/We do not wish to nominate anyone for this demat account. 
I 	/ We the Sole Holder  / Joint Holders  / Guardian(in case of Minor)hereby nominate the following person who is entitled to receive security 
balances lying in my / our account, particulars whereof are given below, in the event of the death of the Sole Holder or the death of all the Joint Holders. 
BO Account Details 
DP ID :	Client Id :
Sole/ First Holder's Name Mr. / Mrs. / Ms. : 
Second Holder's Name Mr. / Mrs. / Ms. : 
Third Holder's Name Mr. / Mrs. / Ms. : 
Nominee Details 
Name of Nominee : Mr. / Ms. / Mrs. :

Date of Birth (in caseNominee is a Minor) : D
Relationship with the BO (If any) :

COLOURED PHOTOGRAPH
D	M	M	Y	Y	Y	Y
OF
THE NOMINEE

Address of Nominee :

City :
State :	Ph. :
E-mail :

WITH SIGNATURE
OF
THE NOMINEE ACROSS
THE PHOTOGRAPH
Pin : 

As the Nominee is a Minor as on Date, I / We appoint following person to act as Guardian: 
Name of Guardian : Mr. / Mrs. : 
Address of Guardian : 
City :

Pin :	State :
Phone(with STD Code) :

Country :
Mobile : 

Signature of Nominee / Guardian : 
To receive the securities in this  account on behalf of the Nominee in the event of the death of the Sole holder / All Joint Holders 	The Nomination is in accordance 
with the Section109A of the Companies Act 1956, and shall supersede any prior Nomination made by me / us and also any testamentary executed by me / us. 
Specimen Signature of mine / us / person(s) authorised by us are given below.	(Please Sign in Black Ink)

Name of Account Holder(s)

Signature(s)*
OR Thumb Impression(Attested by Gazzetted Officer) 

(6) 
First Holder 
(6) 
Second Holder 

(6) 
Third Holder 
Date:	Place:
NAME & ADDRESS OF WITNESS	(IN CASE OF NOMINEE)
1	s	t	w	i	t	n	e	s	s	2	n	d	w	i	t	n	e	s	s

Signature of 1st witness	Signature of 2nd witness

(To be gilled by DP)
Nomination accepted and registered wide Registration No...	.Dated...
For  MULTIPLEX  CAPITAL LTD.
For Depository Participant
Authorised Signatories 
Note: No Nominations recorded in case of HUF 
6