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NAME OF THE INDIVIDUAL

NAME OF THE CONCERN

RESPONSIBILTY IN THE CONCERN

DATE OF STARTED / PROPOSED TO START

ADDRESS

STATE

DISTRICT

PIN CODE

E MAIL ID

MOBILE NUMBER

LAND PHONE NUMBER

BASIC QUALIFICATION

PROFESSIONAL QUALIFICATION

NATURE OF BUSINESS

PURPOSE OF FUNDS

BRIEF ABOUT THE UTILIZATION OF THE FUND

AMOUNT OF REQUIREMENTS

PERIOD OF REQUIREMENTS

BENEFITS OFFERED TO THE INVESTOR

SECURITY OFFERED FOR THE INVESTMENTS

(YOU CAN WRITE “NIL” IF NO SECURITY IS OFFERED)

USER ID *

PASSWORD *

DECLARATION

The given information are true and I will take all responsibilities for all dealings with any investors

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