KAKKANAD MEDICAL CENTRE PRIVATE LIMITED

NOT FOR PUBLIC CIRCULATION

APPLICATION FORM FOR EQUITY SHARES
FOR SUBSCRIPTION IN PRIVATE PLACEMENT AS SPECIFIC CASE

To
The Board of Directors
KAKKANAD MEDICAL CENTRE
Regd. Office: Aswathy, Santhinikethan Gardens,
Kavumpady Road,
Muvattupuzha - 686 661.
Kerala, India. Tel: 0485-2812215, 2812283 (Corp.)
3090285, 2837759 (Off.), Fax: 0484-2812484
e-mail: drnnasokan@hotmail.com, sajeshasokan@hotmail.com
www.kmc-ekm.org, kmc@kmc_ekm.org

APPLICATION NO.
Application must be made n multiples of 100 subject to a minimum of 100 Equity Shares.
Amount Payable on application Rs. 1,000 per Equity Share at par
Date : - -

Cheque/Draft shuld be drawn in the name of KMC payable at Ernakulam

Dear Sirs,
I/We hereby apply for allotment to me / us the Equity Shares in your company. The amount payable for allotting the shares is remitted herewith. I / We note that the Board of Directors are entitled in their absolute discretion to accept or reject the application in whole or in part without assigning any reason whatsoever. I / We agree to accept the Equity Shares applied for or such lesser number as may be allotted to me/us subject to the terms of this application form and the Memorandum and Articles of Association of the company. I/We undertake that I/We will sign all such other documents and do all such other acts, if any, necessary on my/our part to enable me / us to be registered as the holder(s) of the Equity Shares which may be allotted to me/us. I / We authorise you to place my/our name(s) on the Register of Members of the company as the holder(s) of Equity Shares and to register my / our address(es) as given below.

Nationality and Residentship (Tick whichever is application)

I / We confirm that I am / We are Indian National(s) Resident in India and I am / We are not applying for the Equity Shares as Nominee(s) of any person(s) Resident aborad or any Foreign National(s).

I am / We are Indian National(s) Resident in India and I am / We are applying for the said Equity Shares as Power of Attorney Holder(s) of Non-Resident(s) mentioned below on Non-Repatriation basis.

I am / We are Indian National(s) Resident outside India and I am / We are applying for the said Equity Shares on my / our own behalf on Non-Repatriation basis.

No. of Equity Shares Applied	In Figures	In Words
No. of Equity Shares Applied
Amount Rupees

Cheque/DD. No. Date
Drawn On

FIRST / SOLE APPLICANTS BANK ACCOUNT DETAILS

Bank
Branch		Account No.

Date of Birth of Minor
Day	Month	Year	Age

TICK WHICHEVER IS APPLICABLE

Status Individual Registered Scoiety Company Statutory Corporation Parent/Guardian of Minor Trust
Occupation Agriculture Business Professional Service Retired Housewife Student Others

FIRST / SOLE APPLICANT USE ONE BOX FOR ONE ALPHABET LEAVING ONE BOX BLANK BETWEEN FIRST, SECOND & SURNAME

NAME IN FULL (mr/Mrs/Miss
FULLL ADDRESS (P.O. Box No. alone is not sufficient) PIN CODE
FULL NAME OF FATHER/HUSBAND (Mr.)
SECOND APPLICANT FULL NAME (Mr / Mrs / Miss)
THIRD APPLICANT FULL NAME (Mr / Mrs / Miss)

	FIRST / SOLE APPLICANT	SECOND	THIRD
USUAL SIGNATURE
PAN / GIR No.
Circle / Ward / District

TO BE FILLED IN ONLY IF THE APPLICATION IS FROM AN INSTITUTION

Names of authorised Signatories	Designation	Signatures
1.	1.	1.
2.	2.	2.
3.	3.	3.

TO BE FILLED IN WHEN APPLICANT IS / ARE NRI(S)

TO BE FILLED BY ALL APPLICANT SPECIMENT SIGNATURES

LOCAL ADDRESS
NRO / NRI A/c No.
Name of Bank
Address

Sole / First Applicant
Second Applicant
Third Applicant