Annexure CS-S1 Page 1

APPLICATION FORM FOR SUBSCRIBER REGISTRATION

Sir/Madam,
I hereby request that a NPS account to be opened in my name and Permanent Retirement Account number (PRAN) be allotted as per particulars given below:
Section A Subscriber's Personal Details
1. Full Name (Full expanded name: Initials are not permitted)
Please Tick as applicable Shri Smt Kumari
First Name *
S A U M I N D R A
Middle Name

Last Name
B H A T T A C H A R Y A

I would like my PRAN card to be printed in HINDI: Yes No (If Yes, please provide the details in the annexure CS-S1on Page No9)
2.Gender* Male Female

3. Date of Birth * 0 1 1 0 1 9 6 6 4. PAN A B C P B 1 4 7 6 G

D D M M Y Y Y Y (for PAN, please refer to Sr. No. 3 of the instructions)

5.Father's Full Name :

First Name *
P A R B O T I
Middle Name
S A N K A R
Last Name
B H A T T A C H A R Y A

6. Present Address* (Fields marked with* are mandatory):

Flat/Unit No, Block no.*
6 B ,
Name of Premise/Building/Village
T O W E R - 4
Area/Locality/Taluka
3 7 5 P . A . R O A D
District/Town/City*
K O L K A T A
State / Union Territory*
W E S T B E N G A L
Country*
I N D I A

Pin Code* 7 0 0 0 6 8

7. Permanent Address*:If same as above, Please Tick else, {Fields marked with* are mandatory}:
Flat/Unit No, Block no.*
6 B ,
Name of Premise/Building/Village
T O W E R - 4
Area/Locality/Taluka
3 7 5 P . A . R O A D
District/Town/City*
K O L K A T A
Annexure CS-S1 Page 2

State / Union Territory*

W E S T B E N G A L
Country*
I N D I A

Pin Code* 7 0 0 0 6 8

8.Phone No.

STD Code. Phone No.

9. Mobile No. + 9 1 9 9 0 3 0 3 3 5 6 5

10. Email ID
S O M U _ B H A T T A C H A R Y A @ Y A H O O . C O M

11. Do you want to subscribe to SMS Alerts Yes No

12. Subscriber's Bank Details : (please refer to Sr. No. 6 of the instructions)
Savings A/c Current A/c

Bank A/c Number

2 0 0 7 3 1 9 7 5 6 0

Bank Name
S T A T E B A N K O F I N D I A

Bank Branch
J O D H P U R P A R K

Bank Address
3 9 4 A G A R I A H A T R O A D ( S O U T H ) K O L
K A T A

7 0 0 0 6 8
Pin Code

7 0 0 0 0 2 3 3 4
Bank MICR Code

S B I N 0 0 1 1 5 3 9
IFS code (Wherever

Section B - Subscribers Employment Details to be filled and attested by Corporate (All Details are Mandatory)

0 7 0 1 2 0 1 3 0 1 1 0 2 0 2 6
1. Date of Joining* 2. Date of Retirement *:

D D M M Y Y Y Y D D M M Y Y Y Y

3. Employe ID* : V N 0 0 2 8 0 9

4. Corporate Regd. No. 5 5 0 3 8 0 5 5. CBO No. allotted by CRA*: 6 5 0 3 9 6 5

allotted by CRA
Annexure CS-S1 Page 3

Section C - Subscriber's Nomination Details(OPTIONAL -please refer to Sr.No 7&8 of the instructions)
1. Name of the Nominee:
1st Nominee 2nd Nominee 3rd Nominee
First Name* First Name* First Name*
M A L L I K A

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

B H A T T A C H A R Y A

2.Date of Birth(In case of a minor):

1st Nominee 1 8 0 4 1 9 7 0 2nd Nominee 3rd Nominee

3.Relationship with the Nominee:

1st Nominee 2nd Nominee 3rd Nominee
S P O U S E

4.Percentage Share:
1st Nominee 1 0 0 % 2nd Nominee % 3rd Nominee %

5.Nominee's Guardian Details(in case of a minor Nominee):

1st Nominee's Guardian Details 2nd Nominee's Guardian Details 3rd Nominee's Guardian Details
First Name* First Name* First Name*

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

Section D- Subscriber Scheme Preference (Please refer the instructions of Section D Page No. 8 for further details):

(Applicable, only if your corporate has given option to the subscriber to select the scheme details. Kindly Contact your Employer for further details)

(i). PFM Selection for Active and Auto Choice*

(Selection of PFM is mandatory both in Active and Auto Choice. In case you do not indicate a choice of PFM, your
application form shall be summarily rejected).
Annexure CS-S1 Page 4
(ii). Investment Option

Active Choice Auto Choice

(For details on Auto Choice, please refer to the PFRDA website www.pfrda.org.in)
Note:-
1. In case you do not indicate any investment option, your funds will be invested in Auto Choice
2. In case you have opted for Auto Choice, DO NOT fill up section (iii) below relating to Asset Allocation. In case you
do, the Asset Allocation instructions will be ignored and investment made as per Auto Choice.

(iii) Asset Allocation (to be filled up only in case you have selected the 'Active Choice' investment option)

E
Asset Class C G Total
(Cannot exceed 50%)
% share 100%

Note:-

The allocation across E, C and G asset classes must equal 100%. In case, the allocation is left blank and/or does
not equal 100%, the application shall be rejected.
 Annexure CS-S1 Page 5

TIER II DETAILS

I hereby submit the following details for activation of Tier – II account under NPS.

1. Subscriber’s Bank Details*:(MANDATORY - please refer to Sr. No. 6 of the instructions)

If same as Tier I, Please Tick else, fill in the details below:

Savings A/c Current A/c

Bank A/c Number*

Bank Name*

Bank Branch*

Bank Address*

Pin Code*

Bank MICR Code *

IFS code (Wherever applicable)

2. Subscriber’s Nomination Details (OPTIONAL - please refer to Sr. No. 7 & 8 of the instructions)

If same as Tier I, Please Tick else,

Name of the Nominee:
1st Nominee 2nd Nominee 3rd Nominee
First Name* First Name * First Name*

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

Date of Birth (In case of a minor)*:

1st Nominee * 2nd Nominee * 3rd Nominee *

Relationship with the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

Percentage Share:
1st Nominee % 2nd Nominee % 3rd Nominee %

Nominee’s Guardian Details (in case of a minor):

1st Nominee’s Guardian Details 2nd Nominee’s Guardian Details 3rd Nominee’s Guardian Details
First Name* First Name * First Name*

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

Subscriber Scheme Preference (Please refer the Section D on Page No. 8 for further details):
If same as Tier I, Please Tick else,
 Annexure CS-S1 Page 6

i). PFM Selection for Active and Auto Choice (Select only one PFM)

PFM Name (in alphabetical order) Please tick only one

ICICI Prudential Pension Funds Management Company Limited

IDFC Pension Fund Management Company Limited

Kotak Mahindra Pension Fund Limited

Reliance Capital Pension Fund Limited

SBI Pension Funds Private Limited

UTI Retirement Solutions Limited

(Selection of PFM is mandatory both in Active and Auto Choice. In case you do not indicate a choice of PFM, your application form shall be
summarily rejected).
(ii). Investment Option
Active Choice Auto Choice ( (For details on Auto Choice, please refer to the Offer Document)
Note:-
 In case you do not indicate any investment option, your funds will be invested in Auto Choice
 In case you have opted for Auto Choice, DO NOT fill up section (iii) below relating to Asset Allocation. In case you do, the Asset
Allocation instructions will be ignored and investment made as per Auto Choice.

(iii). Asset Allocation (to be filled up only in case you have selected the ‘Active Choice’ investment option)
E
Asset Class C G Total
(Cannot exceed 50%)
% share 100%
Note:- The allocation across E, C and G asset classes must equal 100%. In case, the allocation is left blank and/or does not equal 100%, the
application shall be rejected by the POP.

Section D – Declaration & Authorization (Tier I & II)

I hereby declare and agree that (a) I have read and understood the Offer Document, terms & conditions or the same was
interpreted to me, and the answers entered in the application are mine. (b) I am a Citizen of India. (c) I have not been found or
declared to be of an unsound mind under any law for the time being in force. (d) I am not an undischarged insolvent. (e) I do
not hold any pre-existing account under NPS.
I understand that there would be PFRDA approved Terms and Conditions for subscribers on the CRA website governing I-pin
(to access CRA/NPSCAN and view details) & T-pin. I agree to be bound by the said terms and conditions and understand that
CRA may, as approved by PFRDA, amend any of the services completely or partially without any new
Declaration/Undertaking being signed.

Declaration for availing of Swavalamban benefit (Please strike off if not applicable)
I have read the Swavalamban guidelines and I meet the prescribed eligibility criteria for assistance under the scheme. I also
undertake to adhere to the prescribed contribution limit of minimum Rs. 1000/- and maximum of Rs. 12000/-, failing which the
Central Government contribution credited to my account may be forfeited along with such interest rates as may be prescribed.

Declaration under the Prevention of Money Laundering Act, 2002

I hereby declare that:
1. The contribution paid has been derived from legally declared and assessed sources of income.
2. I understand that the PFRDA/NPS Trust has the right to peruse my financial profile and also agree that the
PFRDA/NPS Trust has the right to close the NPS account in case I am found guilty of violating the provisions of any
Law, directly or indirectly, by any Competent Court of Law, having relation to the laws governing prevention of
money laundering in the country.

I _________________________________________________________________, the applicant, do

hereby declare that the information provided above is true to the best of my knowledge & belief.

Date : (DD/MM/YYYY) Signature/Thumb

Impression* of Subscriber
 Annexure CS-S1 Page 7
To be
Filled by POP
A. POP Registration No. 5 0 0 0 3 4 3

B. KYC Compliance: Yes No

C. KYC document accepted for identity proof: __________________________________________

D. KYC document accepted for address proof: __________________________________________

E. Document accepted for date of birth proof: __________________________________________

F. PAN Compliance: Yes No

G. Copy of PAN Card Submitted: Yes No

H. Submitted Cancelled Cheque: Yes No

Signature of Authorized Signatory

Name : ___________________________________ Place : __________________

Designation : ________________________________ Date : - -

D D M M Y Y
Department : ________________________________
POP Seal

[To be filled by CRA /CRA-FC)]

Received by: __________________________________ CRA-FC Registration Number: _______________________

Received at:_____________________________________ Date:______________

Acknowledgement Number (by CRA-FC)

INSTRUCTIONS FOR FILLING THE FORM

a) Form to be filled legibly in BLOCK LETTERS and in BLACK INK only. Please fill the form in legible handwriting so as to avoid errors in your
application processing. Please do not overwrite. Corrections should be made by cancelling and re-writing and such corrections should be counter-signed
by the applicant.
b) Each box, wherever provided, should contain only one character (alphabet/number/punctuation mark) leaving a blank box after each word.
c) The subscriber should affix a recent color photograph (size 3.5 cm x 2.5 cm) in the space provided on the form. The photograph should not be stapled or
clipped to the form. (The clarity of image on PRAN card will depend on the quality and clarity of photograph affixed on the form.)
d) Signature /Thumb impression (LTI in case of males and RTI in case of females) should only be within the box provided in the form. The subscriber
should not sign across the photograph. If there is any mark on the photograph such that it hinders the clear visibility of the face of the subscriber, the
application shall not be accepted.
e) Applications incomplete in any respect and/or not accompanied by required documents are liable to be rejected. The application is liable to be rejected if
mandatory fields are left blank or the application form is printed back to back.
f) The subscriber’s thumb impression should be verified by the designated officer of the employer accepting the form.
g) Subscribers are advised to retain the acknowledgement slip signed / stamped by the employer where they submit the application.

Sr.
Item No. Item Details Guidelines for Filling the Form
No.
Subscriber’s Personal Details
Please state your name as mentioned in the Proof of Identity failing which the application is liable to be rejected.
If the Proof of identity has a name by which the applicant has been known differently in the past, than the one
1. 1 Full Name
provided in this application form, then requisite proof should be provided e.g. marriage certificate, or gazetted
copy of name change.
2. 3 Date of Birth Please ensure that this matches with the Date of Birth as indicated in the document provided in support.
3. 4 PAN Please provide copy of the your PAN card.

4. 6, 7 Present Address All future communications will be sent to present address.

Annexure CS-S1 Page 8

5. Contact No. &

9, 10, 11 It is advisable to mention either “Telephone number” or “Mobile number” or “Email ID” so that Subscriber can
be contacted in future.
Email ID

For Tier I, bank details are optional, however, if a subscriber mentions any of the bank details(except MICR
Code), all the bank details shall mandatory.
6. 12 Bank Details
For activation of Tier II, bank details are mandatory. The subscribers shall provide a cancelled cheque, the
details of which should match the bank details provided for Tier II

Subscriber’s Nomination Details - Section C

1) Subscriber can nominate a maximum of three nominees.
2) Subscriber cannot fill the same nominee details more than once.
Percentag 3) Percentage share value for all the nominees must be integer. Decimals/Fractional values shall not be accepted in the
7.
e Share nomination(s).
4) Sum of percentage share across all the nominees must be equal to 100. If sum of percentage is not equal to 100, entire
nomination will be rejected.
Nominee’
s
8. If a nominee is a minor, then nominee’s guardian details shall be mandatory.
Guardian
Details
Illustrative list of documents acceptable as proof of identity and address
No. Proof of Identity (Copy of any one) No. Proof of Address (Copy of any one)
1 School Leaving Certificate 1 Electricity bill^
2 Matriculation Certificate 2 Telephone bill^
3 Degree of Recognized Educational Institution 3 Depository Account Statement^
4 Depository Account Statement 4 Credit Card Statement^
5 Bank Account Statement / Passbook 5 Bank Account Statement / Passbook^
6 Credit Card 6 Employer Certificate^
7 Water Bill 7 Rent Receipt^
8 Ration Card 8 Ration Card
9 Property Tax Assessment Order 9 Property Tax Assessment Order
10 Passport 10 Passport
11 Voter’s Identity Card 11 Voter’s Identity Card
12 Driving License 12 Driving License
13 PAN Card
Certificate of address signed by a Member of Parliament or Member
Certificate of identity signed by a Member of Parliament or
13 of Legislative Assembly or Municipal Councillor or a Gazetted
14 Member of Legislative Assembly or Municipal Councillor or a
Officer.
Gazetted Officer.
Note: 1) Proof of Address mentioned in Sr. No. 1 to 7 (^) should not be more than six months old on the date of application.
2) You are required to bring original documents & two self-attested photocopies (Originals will be returned over-the-
counter after verification)

Subscriber Scheme Preference - Section D

Kindly do not fill this section if your organisation has selected the scheme perference details for its subscribers.
Active choice
1. PFM selection is mandatory. Kindly make a choice from Option A. The form shall be rejected if a PFM is not opted for.
2. Allocation under Equity (E) cannot exceed 50%
3. A subscriber opting for active choice may select the available asset classes (“E”, “G”, & “C”). However, the sum of percentage allocation across all the
selected asset classes must equal 100. If the sum of percentage allocations is not equal to 100%, or the asset allocation table at Sr. No. (iii) is left
blank, the application shall be rejected.

Auto choice

4. A subscriber opting for Auto Choice must also select a PFM from “Option A” of PFM Selection. The application shall be rejected if the
subscriber does not indicate his/her choice of PFM
5. In case both investment option and the asset allocation at Sr. No. (ii) and Sr. No. (iii) are left blank, the subscriber’s funds will be invested as per
Auto Choice

For more details on investment options and asset classes, please refer to the PFRDA website www.pfrda.org.in’

GENERAL INFORMATION FOR SUBSCRIBERS

a) For any further clarification please refer to the PFRDA website www.pfrda.org.in or call on our toll free no. 1800110708
b) The Subscriber can obtain the status of his/her application from the CRA website or through the respective employer.
c) For more information
Visit us at http://www.npscra.nsdl.co.in
Call us at 022-24994200
e-mail us at info.cra@nsdl.co.in
Write to: Central Recordkeeping Agency, National Securities Depository Limited, 4th Floor, ‘A’ Wing, Trade World, Kamala Mills
Compound, SenapatiBapatMarg, Lower Parel (W), Mumbai - 400 013.
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