Name & Address of Investor
Nature Of Complaint
( i ) Dividend ________ non-receipt of :
Dividend
( ii ) Shares ________non-receipt of certificates in / after :
Endorsement
Transfer
( iii ) Miscellaneous ________ non-receipt of :
Annual Report
Registration of change in address
Any Other
Specify :
Particulars of application/securities held
(a) Full name of first applicant/ security holder
(b) Folio No. (Seller's in case of transfer)
(c) No. of Securities applied / held
(d) Kind of security
Shares
Others
(e) Original refund order no. (in case of revalidation/duplicate)
(f) Date on which securities were forwarded to Company / Registrars
January
February
March
April
May
June
July
August
September
October
November
December
(Month)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(date)
(Year, eg.2000)
g) Indemnity Bond sent or issue of duplicate
Yes
No
If yes , Date :
January
February
March
April
May
June
July
August
September
October
November
December
(month)
(date)
(year, eg.2000)
Any other message, in brief
Dates of earlier correspondence with the Company / Registrars
Place
Date
