Investor forms

DCRF (NSDL).

Dematerialisation Conversion Request Form — accessible edition. Complete it here, print it or save it as a PDF, then sign it and send it to us.

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Download DCRF (NSDL) as a PDF Alternate format — the printed form, to fill in by hand. PDF

Issuer / Registrar and Transfer Agent Name

Issuer / Registrar and Transfer Agent Address

Registrar and Transfer Agent ID

Date :

I/We request you to provide following service and dematerialize the securities into my/our account as per the details given below:

Service RequestTick the relevant

Issue of duplicate security certificateClaim from unclaimed suspense accountRenewal / Exchange of securities certificateEndorsementSub-division / Splitting of security certificatesConsolidation of security certificates / foliosTransmissionTranspositionAny other services (Please specify)

Any other services (Please specify)

DP ID

Client ID

Sole/First Holder Name

Second Holder Name

Third Holder Name

Type of Security

EquityOthers (please specify)

Others (please specify)

Quantity to be dematerialised

(in figures)

(in words)

Face Value

ISIN(To be filled up by the Issuer / R&T Agent)

Details of Securities:
Folio No	Certificate Nos.		Distinctive Nos.		Quantity
	From	To	From	To
Folio No	Certificate Nos. From	Certificate Nos. To	Distinctive Nos. From	Distinctive Nos. To	Quantity
Folio No	Certificate Nos. From	Certificate Nos. To	Distinctive Nos. From	Distinctive Nos. To	Quantity
Folio No	Certificate Nos. From	Certificate Nos. To	Distinctive Nos. From	Distinctive Nos. To	Quantity
Folio No	Certificate Nos. From	Certificate Nos. To	Distinctive Nos. From	Distinctive Nos. To	Quantity
Folio No	Certificate Nos. From	Certificate Nos. To	Distinctive Nos. From	Distinctive Nos. To	Quantity

Declaration

I/We hereby declare that I/We are the registered owner / claimant of the above-mentioned securities. 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	Sole/ First HolderSign here by hand after printing.
Second Holder	Second HolderSign here by hand after printing.
Third Holder	Third HolderSign here by hand after printing.

Participant Authorisation

We have verified and certify that the holders of the beneficiary account with us are held in the same name(s) with the above conversion request for dematerialisation

Name of the Executive:

Signature:Sign here by hand after printing.

Participant’s Stamp & DateSign here by hand after printing.

Acknowledgement

Serial No. (pre-printed)

We hereby acknowledge the receipt of

service request for

shares/units/bonds/

debentures of

for conversion into dematerialisation by

Mr/Ms/M/s

having

DP ID

and

Client ID

Date :

Issuer / R&T Agent Stamp & SignatureSign here by hand after printing.