Registration No: RM/Associate Code: RM/Associate Name:

Note: Please refer the instructions at the end of form.

Common Registration form for ICICIdirect Institute Classroom Programmes

Programme Applied

Programme Date__________________ City__________________

Foundation Programme on Stock Investing Technical Analysis

Beginners Programme on Futures & Options Trading Advanced Derivatives Trading Strategies

Participant Details

Name: Mr. / Ms. / Dr. ______________________________________

(BLOCK LETTERS)

DOB (DD/MM/YYYY) ____________________

Correspondence Address

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

City ___________________________ State _____________________ Pincode ________________________

Contact Details

Mobile: +91____________________ Landline: ( ) ________________ Email Id: ___________________________________

Payment Details

DD/Net Banking Ref No.: Drawn on (Bank) Branch

Favoring: Amount Location

Customer Signature ____________________________

For office use only

Acknowledgment
Registration No.

Received with thanks from: _______________________________________________________________________________________________________________________________

Rs.________________ Rupees ( In Words )___________________________________________________________________________________

Vide DD No:_________________________________________________

Drawn On Bank: _________________________________________________________________________________________________________________________________________

Towards the registration fee for _________________________________________________________________________________________________________________________

Sign & Seal

Notes:
1. If you are registering without the assistance of our Relationship Manager, please follow these steps:
I. Get your registration number by calling programme coordinator Ms. Bhavika Lad at 09820890816.

II. Please take a print of the form, fill-up the same and attach a DD (of amount shared with the programme details) and send it to: Bhavika Lad, ICICI Securities Ltd, Plot No. D-507, TTC Industrial Area, MIDC,
Turbhe, Navi Mumbai- 400705
2. Refund Policy in case participant initiates cancellation:
I. If refund request is placed atleast 3 days prior to programme: Rs. 500 will be deducted from the fee amount.
II. If refund request is placed between 1 day to 3 days prior to programme: Rs. 1000 will be deducted from the fee amount.
III. If refund request is placed in less than 24 hours of commencement of programme: No fee will be refunded.
All requests can be emailed to education@icicisecurities.com

Disclaimer: ICICI Securities Ltd (I-Sec), may at its sole discretion reschedule and cancel the programme. In case I-Sec cancels any scheduled programme, your fees will be refunded. Please note that in the event
of cancellation of programme by I-Sec, the liability of I-Sec will be limited to the amount of programme fee only.
Disclaimer: ICICI Securities Ltd (I-Sec), may at its sole discretion reschedule and cancel the programme. In case I-Sec cancels any scheduled programme, your fees will be refunded. Please note that in the event
of cancellation of programme by I-Sec, the liability of I-Sec will be limited to the amount of programme fee only.