1. Investor Name
Address of the Investor
2. Name of the Company
Address of the Company
3. Email Address
4. Name of the Registrar & Transfer Agent (if any)
5. PSE Acknowledgement Reference No.
(in case of reminder)
Reminder discription (in case of acknowledgement ref.no.)
6. Nature fo Complaint Type/Category
(i)Issue / offers - non-receipt of
Refund Order / Allotment Advice
Revalidation of Refund Order (RO)
Duplicate RO for correct amount
Duplicate RO after Indemnity
Cancelled Stock Invest (S.I.)
RO after details furnished
Copy of encashed RO
Duplicate RO for correct bank details
Allot against encashed S.I.
Duplicate RO after correction
Short Refund
(ii)Dividend - non-receipt of Dividend
(iii)Shares - non-receipt of certificates in/after Exchange of allotment letter
Conversion
Splitting
Transfer
Endorsement
Bonus
Transmission
Consolidation
Duplicate on submission of idemnity bond
(iv)Debentures/Bond - non-receipt of certificates in/ after Interest
Transfer
Consolidation
Redemption Amount
Transmission
Splitting
Exchange of Allotment Letter
Endorsement
Duplicate on submission of indemnity bond
Interest on delayed interest payment
Interest on delayed redemption amount
(v)Miscellaneous - non-receipt of Interest on delayed refund payment
Offer for Rights
Any other (specify below)
7.Particulars of the application/securities held
a) Full name of first applicant/security holder
b) Application form No.
c)No. of Securities applied/held
d) Kind of Security
Debenture
Shares
e) Mode of payment details
Cash
Cheque
No.Dated.
Drawn On
f) Application deposited at
g) Bank serial No.
h) Original refund order No.(in case of revalidation/
i) Period on/for which dividend/interest/maturity
amount/redemption amount due
j) Date on which securities were forwarded to
Company/Registrars
k) Indemnity Bond sent for issue of duplicate
No
Yes
If Yes Date
8. Other details if any, in brief
9. Dates of earlier correspondence with the Company/Registrars
