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Town/City 

District 

State 

Pin Code 

Residential Address 

Town/City 

District 

State 

Pin Code 

Note: Additional Sheets may be attached if needed. 

Details of shares/ Debentures Held at Date of AGM *

Ledger Folio of share/ Debenture Holder 

Share/ Debenture Holder’s Name 

Surname

Middle Name

First Name

Father’s/ Husband’s Name 

Type of Share/ Debenture 

1 – Equity, 2- Preference Shares, 3 – Debentures, 4 - Stock 

Number of Shares/ Debentures Held/ Stock, if any 

Amount per Share (in Rs.) 

Ledger Folio of share/ Debenture Holder 

Share/ Debenture Holder’s Name 

Surname

Middle Name

First Name

Father’s/ Husband’s Name 

Type of Share/ Debenture  

1 – Equity, 2- Preference Shares, 3 – Debentures, 4 - Stock  

Number of Shares/ Debentures Held/ Stock, if any  

Amount per Share (in Rs.)  

Ledger Folio of share/ Debenture Holder  

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