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Annexure –JA FORM FOR NOMINATION/ CANCELLATION OF …

D - 5 Annexure JAFORM FOR nomination / CANCELLATION OF nomination (To be filled in by individual applying singly or jointly)Name and address of Participant (pre-printed) DPIDINC lient IDDateDDMMYYYY(A) nomination OptionI/We wish to make a nomination . I/We wish to cancel the nomination made by me/ us earlier and consequently all rights and liabilities in respect of beneficiary ownership in the securities held by me / us in the said account shall vest in me/ us. [Strike off (B) nomination Details below](B) nomination DetailsI/We wish to make a nomination and do hereby nominate the following person in whom all rights and / or amount payable in respect of securities held in the Depository by me / us in the said beneficiary owner account shall vest in the event of my / our Name of the Nominee ( )2 Relationship with the Applicant (if any)3 Address of NomineeCity/Town/VillagePIN CodeStateCountry4 Contact Details of nomineeTel.

D - 5 Annexure –JA FORM FOR NOMINATION/ CANCELLATION OF NOMINATION (To be filled in by individual applying singly or jointly) Name and address of Participant (pre-printed) DPID I N Client ID

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