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Customer Full Name : Gender: Age : Occupation : Introducer Type: Introducer Name: Permanant address : Employee Agent Customers

Others Male: Female: DOB

Temporary / current Address:

Enter Mobile No1: Enter Mobile No2: Telephone No


Family Detail

Father / Husband Mother Wife Son 1 Son 2 Daughter 1 Daughter 2 Anniversary Type of Income
Type of Income

DOB DOB DOB DOB DOB DOB DOB

Single Source

Multiple Source

Private

Goverment

Self Employed

Rent

Approximate Family Income /Month

Asset Detail

House Houses Lands Shares Others


Approximate Asset Value

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