KNOW YOUR CLIENT (KYC) APPLICATION FORM

For Individuals
Please fill this form in ENGLISH and in BLOCK LETTERS
A. IDENTITY DETAILS
1. Name of the Applicant:

_________________________________________________________

2. Fathers/ Spouse Name

_________________________________________________________

3. a. Gender:

Male/ Female

c. Date of birth: ____________

(DD/MM/YY)

4. a. Nationality: ___________________________
c. US Residency

b. Marital status:

b. Status: Resident Individual/ No

Yes / No

6. Specify the proof of Identity submitted: _________________________________________________

ADDRESS DETAILS

1. Residence Address: _____________________________________________________________________

________ City/town/village: ___________ P.O Box: __________ State: ______________ Country: ___
2. Contact Details: Tel. (Off.) _______ Tel. (Res.) ________ Mobile No.: _________ Fax: _________

3. . Specify the proof of address submitted for residence address:__________________________

4. Permanent Address _____________________________________________________________________

DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you
above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

Signature _________________________
For Office Use
Original Verified Documents received

Name and Signature of the Authorized Signatory

Date _______________________________

List of Document Requested

1. Valid ID or Passport Copy

T (KYC) APPLICATION FORM

Individuals

_______________________________________________

_______________________________________________
Marital status:

Single/ Married

Status: Resident Individual/ Non Resident/ Foreign National

_____________________________________________

_______________________________________

ate: ______________ Country: _________________

ile No.: _________ Fax: _________ Email id: __________

dress:_______________________________________

_________________________________________

wledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the

re that I may be held liable for it.

Date __________________________