Application form has been submitted successfuly!

Your Application Form number is: 4111000953

Form Number

4111000953

Enrolled By *

Member

Payment Mode *

Complimentary Card

Approval Code Print2world

Name of the Applicant Mohammed Nagori

Name of the Applicant as Desired on the card * Dr.Nagori
Sex

Male

Marital Status

Married

Female
Unmarried

Date of Birth *

29/05/1981

(DD/MM/YYYY)

Anniversary

18/04/2012

(DD/MM/YYYY)

Mailing Address (All communication will be mailed here)

Address Line 1 *

LineBunglows
2 Andheri West
101-seashell apts opp NanananiAddress
park, seven

City *

Mumbai
West

Region *

PIN Code *

400061

State *

Maharashtra

District *

Telephone Number
Residence:
Mobile:

Office:
9769993180

Occupation
Annual Income

Email Address:

Mohanagori@gmail.com

Service

Business

0-5lacs

5-10lacs

Professional
10-20lacs

others

20lacs above

Details of vehicle Owned

Type

Vehicle Brand 1

Vehicle Brand 2

Vehicle Brand 3

Two Wheeler
Four Wheeler Ertiga
Brand of Motor Insurance

Credit card owned

Debit card owned

The New India Assurance Co. Ltd.

HDFC Bank

HDFC Bank

United India Insurance Co. Ltd.

SBI

SBI

The Oriental Insurance Co. Ltd.

ICICI Bank

ICICI Bank

MUMBAI SUB

National Insurance Company

Citi Bank

Citi Bank

ICICI Lombard General Insurance

HSBC

HSBC

Tata AIG General Insurance

Standard Chartered

Standard Chartered

Iffco Tokio General Insurance

American Express

American Express

Bajaj Allianz General Insurance

AXIS Bank

AXIS Bank

Maruti

Other Bank

Date of Expiry of Motor Insurance:

Other Bank
(DD/MM/YYYY)

Unique identifiers for Petro

Place of
Birth

Mother's Maiden
Name Razia

Dahran

Identification Document
Document No.
*

Document Type. * Passport

L6030865

Driver Loyalty card

Referral PetroCard No

HMV / LCV :

Driver License No *

Yes
Multi
Point
Fueling
Type of
Vehicle
Driven

Yes

No

6 Wheeler

10 Wheeler

Trailers

Tractors

Mini Truck

Monthly Fuel Consumption *

Main
Route of
Travel

--Select--

--Select--

--Select--

other

*
Are you
an
existing
customer

Yes

I do not want to receive information on special offers and SMS updates

Application Details

Applied
Place
*

Mumbai

Applied Date
*

02/06/2016

(DD/MM/YYY

Statement Delivery

Mail

E-Mail

I declare that I have read the Terms and Conditions* mentioned and I agree that by using the Petro Card I accept
the same. The information provided on the application is correct and true to the best of my knowledge and any
misrepresentation of the facts will amount to termination of the card.
Signature________________________
Please take print out of the filled in form, sign,affix photograph and attach copy of the same KYC documents that
were uploaded and dispatch to the following address within 10 days .
ATOS WORLDLINE INDIA PVT. LTD.
Raiaskaran Tech Park (Logitech Park),
Tower-1, 2nd floor, Phase 2 ,
Sakinaka, Andheri (East),
Mumbai - 400072.
Card will be processed and dispatched to the registered address , only on receipt of duly signed print out of filled
in application form.

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