Ncfmregnform

NATIONAL STOCK EXCHANGE'S CERTIFICATION IN FINANCIAL MARKETS (NCFM) REGISTRATION FORM (Please read instructions on page 2 carefully before filling up the form) FIRST NAME

MIDDLE NAME

SURNAME

PART-I (In case you are already registered, please ignore Part I and fill-up Part II and III) NAME TO BE PRINTED ON CERTIFICATE

DATE OF BIRTH (DD-MMM-YYYY) -

Recent Passport size Colour Photograph

MALE/FEMALE

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ADDRESS FLAT NO/ H.NAME & NO.__________________________________________ STREET NAME : _________________________________________________ VILLAGE/AREA/DISTRICT : ________________________________________ LANDMARK : ____________________________________________________ (Candidates Signature- Sign inside the box)

STATE : ______________________________________________________ CITY

PINCODE

OFFICE NUMBER (WITH STD CODE)

RESIDENCE/MOBILE NO: (WITH STD CODE)

E MAIL - (MANDATORY)

QUALIFICATIONS PROFILE YEAR OF PASSING

COURSE

PERCENT / GRADE

UNIVERSITY / INSTITUTE

PART-II TEST DETAILS NCFM-_____________________________ (specify registration number, if already registered under NCFM.) MODULE NAME (Select the desired Module) Capital Market (Dealers) Module Derivatives Market (Dealers) Module in: English language Gujarati language Hindi language Securities Market (Basic) Module Surveillance in Stock Exchanges FIMMDA-NSE Debt Market Module Financial Markets: A Beginners' Module

For Office Use only NSDL Depository Operations Module ? Hand Del/ Courier Commodities Market Module ? Mails of the Day AMFI-Mutual Fund (Advisors) Module ? Chkd/Reg./Scanned AMFI-Mutual Fund (Basic) Module ? Enrollment/DD Entry Corporate Governance Module ? SM Issued/SM Sent Compliance Officers (Brokers) Module Compliance Officers (Corporates) Module Information Security Auditors Module (Part-I) Information Security Auditors Module (Part-II)

Note: Test in Derivatives Market (Dealers) Module is available in English, Gujarati and Hindi languages. Please tick the appropriate language. TEST SCHEDULE TEST CENTRE

TEST DATE D D M M M

Y Y Y Y

TEST TIME : H H M M

Once the test details has been specified by the candidate, the test cannot be rescheduled Fees once paid shall not be refunded.

DD NUMBER 1

DD NUMBER 2

PART-III PAYMENT DETAILS DD NUMBER 3 DD DATE ( DD-MM-YY) -

TOTAL DD AMOUNT

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ISSUING BANK (NAME AND BRANCH) I certify that the above information provided by me is true and correct to the best of my knowledge, information and belief. PLACE DATE

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2

0 0 (CANDIDATE'S SIGNATURE)