8/14/2019 ICICI Prudential SMART Fund

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Date &Time of

ReceiptSerial Num berSub-Broker Code

Broker Code

ICICI Prudential S.M.A.R.T. (Structured Methodology

Aiming at Returns over Tenure) Fund

Application No.

ICICI PRUDENTIAL S.M .A.R.T. (STRUCTURED METHODOLOGY AIM ING AT RETURNS OVER TENURE) FUNDACKNOWLEDGEMENT SLIP (To be f illed in by the Investor)

Received from:

Signature, Stamp & Date

Application No.

Address

1 FOR EXISTING UNITHOLDERS

Date:

Folio No.If you have an existing folio with PAN validation & KYC validation (if applicable), please

mention the folio number in the space provided and proceed to Step 5 . Please note that theapplicable details and mode of holding w ill be as per the existing folio.

2 ABOUT YOU

Account Statement

3 E-MAIL COMM UNICATION I/We wish to receive the following via e-mail instead of physical document:

Quarterly Review & Annual Report Other statutory informati

Name of Third Applicant

Mr. M s.

Name of Second Applicant

Mr. M s.

Overseas Address (in case of NRIs/FIIs)

State

Communication

Tel.(Res.)

E-Mail

Tel.(Off.) Mob

Mailing Address (Please provide full address)

City

PIN

State(Mandatory) Country

Designation of the Contact Person (In case of non-individual investors)

Name of Guardian (in case of minor) /Contact Person (In case of non-individual investors)

Mr. Ms.

Date of Birth (Mandatory)

D D M M Y Y Y

Name of First Applicant

Mr. Ms. M/s.

1st Applicant

Guardian (in case 1stapplicant is minor)

Mode of holding [Please tick

Single

Anyone or Survivor

J

(Default option: Anyone or Surv

Occupation [Please tick ()]

Professional

Business

Retired

House

Service

Studen

Others (Please specify)_______________________________________________________________

(Mandatory)

Status [Please tick ()]

Minor

NRI/PIO

Resident Individual

HUF

Sole Proprietorship

Partnership Firm

Trust

Bank/FI

AOP/Bo

Club/So

Compa

FII

Others (Please specify) _____

______________________

______________________

______________________City

(Mandatory)

ZIP/PIN(Mandatory)(Mandatory)(Mandatory)(Mandatory)(Mandatory)

Country(Mandatory)(Mandatory)(Mandatory)(Mandatory)(Mandatory)

Permanent Account Number (PAN) - Mandatory{Please submit a copy of PAN card. In case the 1st applicant is minor,please provide Guardians PAN. Refer to Instruction No. II-b(4) }

2nd Applicant

3rd Applicant

Copy of KYC acknowledgement enclosed

Copy of KYC acknowledgement enclosed

Copy of KYC acknowledgement enclosed

Copy of KYC acknowledgement enclosed

Know Your Customer (KYC)(Please refer to inst ruct ion no. IX) Please t ick ()(Mandatory for investment of Rs.50,000 & above)

Cumulative Dividend Payout

Sub-Options (Please Tick )Options (Tick any of the boxes below)

Retail Institutional

New Fund Offer Opens on : August 18, 2008 New Fund Offer Closes on : September 19, 2008

(Application to be filled in BLOCK LETTERS in ENGLISH only)

Application Form for

Resident Indians and NRIs/

PIOs/FIIs

Options (Tick any of the boxes below)

Series C - 24 months Series F - 36 months

NJ India Invest / ARN-0155 54934

8/14/2019 ICICI Prudential SMART Fund

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