DEMATERIALISATION REQUEST FORM
For Office Use Only                      

 ZUARI INVESTMENTS LIMITED
[Regd. Office: Jaikisan Bhawan, Zuarinagar, Goa-403 726 (India)]
Corporate Office: F-Block, IInd Floor, International Trade Tower, Nehru Place,     New Delhi - 110019. ,India Tel.: 91-11-26413361 /76/ 86 Fax : 91-11-26413391		 Branch Code & Name ________________
____________________________________
Sr. No. __________________________
Date _____________________________

DP ID:IN 301055

DRN __________________________________
(to be filled-in by the DP)

Date : _________________________________

I/We request you to dematerialize the enclosed certificate(s) into my/our account as per the details give below :
Client ID                
Sole/First Holder Name  
Second Holder Name  
Third Holder Name  
Company Name  
Type of Security Equity Shares/Bonds/Debentures
Quantity to be Dematerialized (in figures)  
(in words)  
Face Value  
ISIN (to be filled in by the DP)                        
Details of Securities:
Free Securities Locked-in Securities

Folio No.

Certificate Nos.

Distinctive Nos.

Quantity

From

To

From

To
           
           
           
           
           
           
           

Total No. of Certificate: ____________________________

Details of Locked-in Securities:
Lock-in reason  
Lock-in release date  
(In Case the space is found to be insufficient, an Annexure containing the certificate details in the same format may be attached. Please use separate form for free securities and locked-in securities).
Declaration
I/We hereby declare that the above mentioned securities are registered in my/our name. The original certificates are hereby surrendered by me/us for dematerialization. I/We also hereby declare that the securities surrendered by me/us for dematerialization 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) Signatures
  
Sole/First Holder
Second Holder
Third Holder


 

 

 
Participant Authorization
 We have received the above mentioned securities for dematerialization. The application form is verified with the certificate(s) surrendered for dematerialization and we certify that the application form is in accordance with the details mentioned in the enclosed certificates, it is certified that the holders of the securities have beneficiary account with us in the same name(s).

Name of Executive:                                                                           Participant's Stamp & Date
Signature