FORM D APPLICATION FOR THE ISSUE OF CERTIFICATE OF PRACTICE See Reg.

10, 13 & 14
To The Secretary to the Council of The Institute of Company Secretaries of India ICSI HOUSE, 22, Institutional Area, odi !oad, New Delhi 110 003 Sir, I furnish "elo# my particulars $i% &em"ership 'um"er ACS( $ii% 'ame in full( $in "loc) letters% Surname $iii% *ate of +irth( $i,% -rofessional Address( $,% -hone 'os. $!esi% $Off.% $,i% &o"ile 'o( Email id( $,ii% Additions to or chan/e in 0ualifications, if any( NIL 1. Su"mitted for $tic) #hiche,er is applica"le%( $a% Issue 2222 $"% !ene#al 222222 $c% !estoration 222222

'ame

2.

$a% -articulars of Certificate of -ractice issued 3 surrendered3Cancelled earlier Sl. 'o. Certificate 'o. NA of -ractice *ate of issue of CNA *ate of surrender 3 Cancellation of C-

NA

4. i. I state that I shall "e en/a/ed in the profession of Company Secretary only on #hole5time "asis and not in any other profession, "usiness, occupation or employment. I am not enrolled as an Ad,ocate on the rolls of any +ar Council and do not hold certificate of practice from any professional "ody includin/ ICAI and the IC6AI. I state that as and #hen I cease to "e in practice, I shall duly inform the Council and shall surrender forth#ith the certificate of practice as re0uired "y the Company Secretaries Act, 1789, and the re/ulations made thereunder, as amended from time to time. I here"y underta)e that, I shall adhere to the mandatory ceilin/ of not more than ei/hty companies in a//re/ate in a calendar year in terms of the Guidelines for Issuing Compliance Certificate and :ours faithfully, -lace(

ii.

iii.

$Si/nature%

Encl. *ate( 22222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222 ; Applica"le in case rene#al or restoration of Certificate of -ractice