ICICI Prudential S.M.A.R.T.

(Structured Methodology
Aiming at Returns over Tenure) Fund
Date &
NJ India Broker
Invest / Code
Application Form for
Resident Indians and NRIs/
ARN-0155 54934
Sub-Broker Code Time of Serial Number
PIOs/FIIs Receipt
New Fund Offer Opens on : August 18, 2008 New Fund Offer Closes on : September 19, 2008
(Application to be filled in BLOCK LETTERS in ENGLISH only) Application No.
1 FOR EXISTING UNITHOLDERS
If you have an existing folio with PAN validation & KYC validation (if applicable), please Folio No.
mention the folio number in the space provided and proceed to Step 5. Please note that the Date:
applicable details and mode of holding will be as per the existing folio.

2 ABOUT YOU
Name of First Applicant Date of Birth (Mandatory)
Mr. Ms. M/s. D D M M Y Y Y Y
Name of Guardian (in case of minor) / Contact Person (In case of non-individual investors) Status [Please tick ()]
Mr. Ms. Minor Trust
NRI/PIO Bank/FI
Designation of the Contact Person (In case of non-individual investors) Resident Individual AOP/BoI
HUF Club/Society
Sole Proprietorship Company
Mailing Address (Please provide full address) Partnership Firm FII
Others (Please specify) _______
_______________________
_______________________
City PIN
(Mandatory) (Mandatory) _______________________
State Country
(Mandatory)
Communication
Tel. Tel.
(Res.) (Off.) Mob

E-Mail
Overseas Address (in case of NRIs/FIIs)

City ZIP/P I N
(Mandatory)

State Country
(Mandatory)

Name of Second Applicant Mode of holding [Please tick ()]

Mr. Ms. Single Joint

Name of Third Applicant Anyone or Survivor

Mr. Ms. (Default option: Anyone or Survivor)

Permanent Account Number (PAN) - Mandatory Know Your Customer (KYC)

{Please submit a copy of PAN card. In case the 1st applicant is minor, (Please refer to instruction no. IX) Please tick ()
please provide Guardian’s PAN. Refer to Instruction No. II-b(4) } (Mandatory for investment of Rs.50,000 & above) Occupation [Please tick ()]

1st Applicant Copy of KYC acknowledgement enclosed Professional Housewife

Business Service
Guardian (in case 1st Copy of KYC acknowledgement enclosed Retired Student
applicant is minor) Others (Please specify)
_____________________
2nd Applicant Copy of KYC acknowledgement enclosed
_____________________
_____________________
3rd Applicant Copy of KYC acknowledgement enclosed

3 E-MAIL COMMUNICATION – I/We wish to receive the following via e-mail instead of physical document:
Account Statement Quarterly Review & Annual Report Other statutory information

  
ICICI PRUDENTIAL S.M.A.R.T. (STRUCTURED METHODOLOGY AIMING AT RETURNS OVER TENURE) FUND
ACKNOWLEDGEMENT SLIP (To be filled in by the Investor) Application No.

Received from:

ess
Addr

Options (Tick  any of the boxes below) Options (Tick  any of the boxes below) Sub-Options (Please Tick  )
Series C - 24 months Series F - 36 months Retail Institutional Cumulative Dividend Payout Signature, Stamp & Date
 4 BANK ACCOUNT DETAILS OF FIRST APPLICANT (Refer instruction No.III)
Bank Particulars (Name of the Bank)
MANDATORY

Branch Address
City
Account Number Account Type
If “Mandatory Details” are not provided,
Current Savings NRO NRE your application is liable to be rejected.
9 Digit IFSC Code
MICR code (11 digit)
Please quote 9 Digit Code No. of your Bank and Branch corresponding to Bank Account details. (This number appears on every leaf of your cheque book after your cheque number). Please
attach a blank “cancelled” Cheque or a clear photocopy of a cheque issued by your bank verifying of the Code No. The AMC reserves the right to make dividend payments through ECS
where MICR code is available.

5 YOUR INVESTMENT DETAILS UNDER ICICI PRUDENTIAL S.M.A.R.T. (STRUCTURED METHODOLOGY AIMING AT RETURNS OVER TENURE) FUND
Plans (Tick  below) Options (Tick  below) Sub-Options (Tick  any of the boxes below) Default Option & Sub-option: Retail with
Cumulative will be the default option & sub-option.
Hence, If an investor fails to specify the option/sub-option
Series C - 24 months Retail Option Cumulative or has selected multiple options/sub-options, he will be
allotted units under the default option/sub-option.
Series F - 36 months Institutional Option Dividend Payout

Amount Invested Cheque/DD No. Cheque/DD Date Account Type (For NRI Investors)
Rs. D D M M Y Y NRO NRE FCNR

Bank Name & Branch

City The cheque/demand draft should be drawn in favour of “ICICI Prudential SMART Fund - Series C - 24
months” or “ICICI Prudential SMART Fund - Series F - 36 months” and crossed “Account Payee
Only”. The cheque/demand draft should be payable at the centre where the application is lodged.

6 NOMINATION DETAILS (Optional) (For single nomination)

I/We hereby nominate the undermentioned Nominee to receive the amounts to my/our credit in event of my/our death. I/We also understand that all payments and settlements made to
such Nominee and signature of the Nominee acknowledging receipt thereof, shall be a valid discharge by the AMC/Mutual Fund/Trustees.
Date of Birth (If nominee is
Name of the Nominee minor) - Mandatory
Mr. Ms. M/s. D D M M Y Y Y Y
Address of Nominee (Please provide full address)

PIN
Code
Name of the Guardian (If nominee is minor) - Mandatory Relationship with minor

Address of Guardian Signature of Guardian / Nominee

PIN
Code
7 YOUR CONFIRMATION
The Trustee, ICICI Prudential Mutual Fund
I/We have read and understood the SID/Key Information
Memorandum of ICICI Prudential S.M.A.R.T. (Structured Methodology Aiming at Returns First Applicant
DD MM YYYY
over Tenure) Fund. I/We apply for the units of the ICICI Prudential S.M.A.R.T. (Structured
Methodology Aiming at Returns over Tenure) Fund and I/we agree to abide by the terms,
SIGNATURE(S)

conditions, rules and regulations of the scheme. I/We confirm to have understood the terms
& conditions. Its investment objectives, investment pattern, fundamental objectives and risk
factors applicable to the Plans under the Scheme. I/We agree to abide by the terms, conditions, Second Applicant
rules and regulations of the Scheme. I/We have understood the details of the scheme and I/
we have not received nor been induced by any rebate or gifts, directly or indirectly, in making
this investment. I/We agree to abide by the terms, conditions, rules, regulations and other
statutory requirements of SEBI, AMFI, Prevention of Money Laundering Act, 2002 and such
other regulations as may be applicable from time to time. I/We declare that the amount
invested in the Scheme is through legitimate sources only and is not designed for the purpose Third Applicant
of contravention or evasion of any Act, Regulation, Rule, Notification, Directions or any
other applicable laws enacted by the Government of India or any Statutory Authority.

REGISTRAR
Computer Age Management Services Pvt. Ltd.
Floor III, Tower 1, Rayala Towers, 158, Anna Salai, Chennai 600 002, Ph: (044) 30212631/673

 
ICICI Prudential S.M.A.R.T. (Structured Methodology Aiming at Returns over Tenure) Fund – ACKNOWLEDGEMENT SLIP (To be filled in by the Investor)
Investment Plan Cheque/DD No. Dated Amount (Rs.) Drawn on (Name of Bank & Branch)