‡mvbvjx e¨vsK wjwg‡UW

kvLv
...........................................
wnmve †Lvjvi Av‡e`b dig
e¨w³ wnmve
ZvwiL t ..................................... wnmve b¤^i t ...............................................
MÖvn‡Ki AvB.wW. b¤^i t.................................
Dc-gnve¨e¯’vcK/mnKvix gnve¨e¯’vcK/e¨e¯’vcK
‡mvbvjx e¨vsK wjwg‡UW
...........................kvLv|
g‡nv`q,
Avwg/Avgiv Avcbvi kvLvq wbgœiƒc GKwU wnmve †Lvjvi Rb¨ Av‡e`b KiwQ| AbyMÖnc~e©K Avgvi/Avgv‡`i e¨env‡ii Rb¨
..................................cvZvi GKwU †PK ewn mieivn Ki‡eb| Avgvi/Avgv‡`i we¯—vwiZ Z_¨ wb‡gœ cÖ`vb Kijvg t
1. wnmv‡ei bvg t ..............................................................................................................................
2. wnmv‡ei cÖKvi (wUK w`b) t …mÂqx … PjwZ … Gm.wU.wW.… ¯’vqx …FC …RFCD …NFCD … Ab¨vb¨....
3. gy`ªv (wUK w`b) t … UvKv … Wjvi … BD‡iv … cvDÛ … Ab¨vb¨ ................
4. wnmve cwiPvjbv msµvš— †Nvlbv (wUK w`b) t … GKKfv‡e … ‡hŠ_fv‡e … ‡h †Kvb GKRb … Ab¨vb¨...........
5. MÖvn‡Ki Ab¨vb¨ e¨vsK wnmve (hw` _v‡K) t

e¨vs‡Ki bvg kvLv cwiPvjbvK…Z wnmv‡ei cÖK…wZ (wUK wPý w`b)

K .............................. K ......................... … Rgv wnmve … FY wnmve … Ab¨vb¨
L .............................. L ......................... … Rgv wnmve … FY wnmve … Ab¨vb¨
M .............................. M ......................... … Rgv wnmve … FY wnmve … Ab¨vb¨

6. cwiPq`vbKvixi Z_¨t
K. bvg t......................................................................................................
L. wcZv/¯^vgxi bvg t......................................................................................................
M. gvZvi bvg t......................................................................................................
N. wVKvbv- eZ©gvb t......................................................................................................
¯’vqx t......................................................................................................
O. wnmve bs t......................................................................................................
P. kvLvi bvg t......................................................................................................
Q. ¯^v¶i (ZvwiLmn) t.....................................................†Uwj‡dvb b¤^i..............................

7. cÖv_wgK Rgv t cwigvb t............................................................................................

8. Gd.wW.Avi msµvš— Z_¨ t cwigvb t....................................................gy`ªv t.................................
†gqv`Kvj t gvm eQi w`b| †gqv`c~wZ©i ZvwiL t........................

bevq‡bi †¶‡Î t … Avmj Ges my` bevqb Ki“b … ïaygvÎ Avmj bevqb Ki“b
… ïaygvÎ Avmj bevqb Ki“b, my` ..............................b¤^i wnmv‡e Rgv Ki“b
… cÖ‡hvR¨ b‡n|
9. we‡kl ¯‹xg msµvš— Z_¨ t
¯‹x‡gi bvg t...............................................................................................................................
¯‹x‡gi ‡gqv` t.....................GKKvjxb Rgv/wKw¯—i cwigvb t.................. wKw¯—i msL¨v (evwl©K) t...............
‡gqv`v‡š— cÖ‡`q t.........................................................gvwmK cÖ‡`q t..............................................
 bwgbxi Av‡jvKwPÎ (d‡Uv)
(MÖvnK KZ…©K mZ¨vwhZ

10. bwgwbx msµvš— Z_¨ t

Avwg/Avgiv GB wnmv‡ei A_© Avgvi/Avgv‡`i g„Zz¨i ci wbgœv³fv‡e wb‡gœv³ e¨w³/e¨w³‡`i‡K cÖ`v‡bi Rb¨ g‡bvbxZ
Kijvg| Avwg/Avgiv Dwj−wLZ g‡bvbqb †h †Kvb mgq evwZj ev cwieZ©‡bi AwaKvi msi¶Y Kwi| Avwg/Avgiv GB g‡g©
Av‡iv m¤§wZ Ávcb KiwQ †h, Avgvi/Avgv‡`i wb‡`©kbv †gvZv‡eK †jb‡`‡b e¨vsK †Kvbfv‡e `vqe× n‡ebv|
bwgbx/bwgbx‡`i bvg t (1)..............................(2)...................................(3)..............................
Rb¥ ZvwiL/eqm t...............................................................................................................
wcZvi bvg t...............................................................................................................
gvZvi bvg t...............................................................................................................
¯^vgx/¯¿xi bvg t...............................................................................................................
bwgbx/bwgbx‡`i t (K) eZ©gvb wVKvbv t...................................................................................
(L) ¯’vqx wVKvbv t...................................................................................
‡ckv t...............................................................................................................
wnmveavixi mv‡_ m¤úK© t...............................................................................................................
As‡ki cwigvb (%) t...............................................................................................................
RvZxq cwiPqcÎ b¤^i t...............................................................................................................
*(†Kvb Awbevmx‡K bwgbx Kiv n‡j H Awbevmx mswk−ó wnmv‡ei A_© cÖvc¨ n‡j cÖvß A_© we‡`‡k †cÖi‡Yi †¶‡Î we`¨gvb ˆe‡`wkK gy`ªv wbqš¿b
AvB‡bi wewa weavb cÖ‡hvR¨ n‡e|)

11. GK ev GKvwaK wnmveavix bvevjK n‡j t

Avwg wbgœewY©Z wnmveavixi ˆea AwffveK wnmv‡e GB g‡g© †Nvlbv KiwQ †h, wnmveavix bvevjK| Zvi cÖ‡qvRbxq Z_¨
mshy³ di‡g cÖ`vb Kiv n‡jv| wnmveavix mvevjK bv nIqv ch©š— wKsev Avgvi KZ…©K cieZ©x †Nvlbv bv †`qv ch©š—
wnmvewU ˆea AwffveK wnmv‡e Avgvi ¯^v¶‡i cwiPvwjZ n‡e|
K. wnmveavix (bvevjK) Gi bvg t.......................................................................................................
L. Awffve‡Ki bvg t.............................................................. bvevj‡Ki mv‡_ m¤úK© t........................
(bvevjK Ges AwffveK - Df‡qi Rb¨B Òe¨w³ msµvš— Z_¨vejxÓ dig c~iY Ki‡Z n‡e Ges Dfq di‡gB Awffve‡Ki ¯^v¶i Ki‡Z n‡e|)
12. A‡_©i Drm t..................................................................................................................................
13. †Nvlbv I ¯^v¶i t
Avwg/Avgiv GB g‡g© wbðqZv cÖ`vb KiwQ †h, Avwg/Avgiv wnmve msµvš— hveZxq wbqgvejx/kZ©vejx c‡owQ Ges D³
wbqgvejx/kZ©vejx †g‡b Pj‡Z eva¨ _vKe| Avwg/Avgiv ¯^Áv‡b †NvlYv KiwQ †h, Dc‡ivwj−wLZ Z_¨vw` mZ¨| Avcbvi
Pvwn`v †gvZv‡eK cÖ`Ë Z‡_¨i AwZwi³ mswk−ó †h †Kvb cÖ‡qvRbxq Z_¨vw`/`wjjvw` mieivn Kie|

Av‡e`bKvixi bvg, ¯^v¶i I ZvwiL

e¨vs‡Ki e¨env‡ii Rb¨

‡PK ewn b¤^i..................................Bmy¨i ZvwiL.............................Kg©KZ©vi ¯^v¶i...................................

gš—e¨ t

......................... .........................
......................... .........................
wnmve †Lvjvi Kg©KZ©v Aby‡gv`bKvix Kg©KZ©v
bvghy³ mxjmn ¯^v¶i I ZvwiL bvghy³ mxjmn ¯^v¶i I ZvwiL
 ............................. e¨vsK / e¨vsK wjt Av‡jvKwPÎ
....................... kvLv
wnmve †Lvjvi dig t e¨w³ msµvš— Z_¨vejx
GB digwU cyiYc~e©K e¨w³ I Ae¨w³K wnmv‡ei g~j As‡ki mv‡_ mshy³ Ki‡Z n‡e|

ZvwiL t ..................................... wnmve b¤^i t ...............................................

MÖvn‡Ki AvB.wW. b¤^i t.................................

1. MÖvn‡Ki bvg t......................................................................................

2. wnmv‡ei mv‡_ m¤úK© (bx‡P cÖ‡hvR¨ †¶‡Î wUK w`b) t

… 1g Av‡e`bKvix … 2q Av‡e`bKvix … 3q Av‡e`bKvix … WvB‡i±i … Askx`vi
… bvevjK … AwffveK … G¨vUb©x †nvìvi … wmM‡bUwiR … Ab¨vb¨ .........................
3. wcZvi bvg t......................................................................................
4. gvZvi bvg t......................................................................................
5. ¯^vgx/¯¿xi bvg t......................................................................................
6. RvZxqZv t......................................................................................
7. Rb¥ ZvwiL t......................................................................................

8. wj½ (wUKv w`b) t … cyi“l … gwnjv

9. †ckv (c`exmn) t......................................................................................
10. RvZxq cwiPqcÎ b¤^i t......................................................................................
11. cvm‡cvU© b¤^i (hw` _v‡K) t......................................................................................
12. U¨v· AvBwW b¤^i (TIN) (hw` _v‡K) t......................................................................................
13. WªvBwfs jvB‡mÝ b¤^i (hw` _v‡K) t......................................................................................
14. eZ©gvb wVKvbv (Avev¯’j) t......................................................................................
15. ¯’vqx wVKvbv t......................................................................................
16. †ckvMZ wVKvbv t......................................................................................
17. †hvMv‡hvM t

‡Uwj‡dvbt evmvt.................................... Awdmt.............................

‡gvevBjt................................ B-‡gBjt................................ d¨v·t..............................
18. †µwWU KvW© msµvš— Z_¨t
Bmy¨Kvix cÖwZôvb I KvW© b¤^i (hw` KvW© e¨enviKvix nb) t 1|............................................................
2|............................................................
19| †iwm‡WÝ ó¨vUvm (wUK w`b) t … †iwm‡W›U … bb-‡iwm‡W›U
(cÖ‡qvRbxq †¶‡Î e¨vsK MvBWjvBÝ di G·‡PÄ Uªvb‡RKkbm Gi wb‡`©kbv AbymiY K‡i Z_¨ msMÖn Ki‡e)

¯^v¶i (ZvwiLmn)
 MÖvnK cwiwPwZ m¤úwK©Z dig (KYC Profile Form)t
(we‡kl ¯‹xg/¯’vqx Avgvb‡Zi †¶‡Î cÖ‡hvR¨)

1. wnmv‡ei bvg t

2. wnmv‡ei aiY t

3. wnmve ev m~Î (Reference) b¤^i t

4. wnmve †Lvjvi Kg©KZ©vi bvg t

5. Znwe‡ji Drm wK ? Znwe‡ji Drm wKfv‡e wbwðZ Kiv n‡q‡Q ? (cÖ‡hvR¨ †¶‡Î) t

6. wnmv‡ei cÖK…Z myweav‡fvMx (Beneficial Owner) m¤úwK©Z Z_¨vw` (†K¤úvbxi †¶‡Î wbqš¿bKvix †kqvi
†nvìvi Ges 20% ev Gi AwaK GKK †kqvi †nvìvi Gi we¯—vwiZ Z_¨vw`) t..............................................
.................................................................................................................................
7. cvm‡cvU© b¤^i .....................................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

8. ‡fvUvi AvBwW KvW© b¤^i.........................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

9. RvZxq cwiPqcÎ b¤^i............................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

10. wU AvBGb ..........................................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

11. f¨vU †iwRt b¤^i...................................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

12. WªvBwfs jvB‡mÝ b¤^i.............................d‡UvKwc M„nxZ wKbv? t nu¨v / bv (cÖ‡hvR¨ †¶‡Î)

13. MÖvnK wK K‡ib ?

MÖvn‡Ki †ckv we¯—vwiZ eY©bv Ki“b t

gš—e¨ (hw` _v‡K) t

(* GB As‡k Subjective we‡ePbvq MÖvnK‡K SuywK m¤ú‡K© gš—e¨ Kiv †h‡Z cv‡i)

---------------------------------------------- ---------------------------------------------
wnmve †Lvjvi Kg©KZ©v/wi‡jkbkxc g¨v‡bRv‡ii Aby‡gv`bKvix Kg©KZ©vi bvg, ¯^v¶i (mxjmn)
bvg, ¯^v¶i (mxjmn) I ZvwiLt I ZvwiLt
 m¤¢ve¨ †jb‡`‡bi AbygwZ gvÎv (Transaction Profile) t

1. wnmv‡ei bvg t

2. wnmv‡ei aiY t

3. wnmve ev m~Î (Reference) b¤^i t

weeiY ‡jb‡`‡bi msL¨v m‡e©v”P †jb‡`‡bi ‡gvU cwigvb

(gvwmK) A¼ (gvwmK)
(cÖwZwU †jb‡`‡bi)
Rgvt

bM` Rgv (AbjvBbmn)

UªvÝdvi/ BÝUªy‡g›U Gi gva¨‡g Rgv

d‡ib †iwgU¨vÝ Rgv

ißvbx n‡Z Avq

Ab¨vb¨ (wbw`©ófv‡e) ....................

†gvU m¤¢ve¨ Rgv

D‡Ëvjbt

bM` Rgv (AbjvBbmn/G.wU.Gg mn)

UªvÝdvi/ BÝUªy‡g›U Gi gva¨‡g cwi‡kva

d‡ib †iwgU¨vÝ D‡Ëvjb

Avg`vbx eve` e¨q

Ab¨vb¨ (wbw`©ófv‡e) ....................

†gvU m¤¢ve¨ D‡Ëvjb

4. †jb‡`bK…Z A‡_©i Drm t .............................................................................................

Avwg/Avgiv wbgœ¯^v¶iKvix(MY) G g‡g© wbðqZv cÖ`vb KiwQ †h, m¤¢ve¨ †jb‡`‡bi AbywgZ gvÎv
Avgvi/cÖwZôv‡bi ¯^vfvweK cÖK…Z †jb‡`b| Avwg/Avgiv Av‡iv wbðqZv cÖ`vb KiwQ †h, cÖ‡qvRb‡ev‡a
Avwg/Avgiv m¤¢ve¨ †jb‡`‡bi AbywgZ gvÎv ms‡kvab/ nvjbvMv` Kie|

¯^v¶i t ¯^v¶i t
bvg t bvg t
c`ex t c`ex t
ZvwiL t ZvwiL t
 ‡mvbvjx e¨vsK wjwg‡UW
I‡qR Avb©vm© ¯‹x‡gi AvIZvq ˆe‡`wkK
gy`ªvi GKvD›U †jb‡`‡bi wbwgË
Ó¶gZv cÎÓ
e¨e¯’vcK/mnKvix gnve¨e¯’vcK/Dc-gnve¨¯’vcK
‡mvbvjx e¨vsK wjwg‡UW ‰e‡`wkK gy`ªv wnmve bstWjvi/cvDÛ/BD‡iv..........
...................................kvLv
......................................... ZvwiLt...........................20
evsjv‡`k|

Rbve,
Avgvi/Avgv‡`i bv‡g Avcbvi e¨vs‡K I‡qR Avb©vm© ¯‹x‡gi AvIZvq †h ˆe‡`wkK gy`ªv wnmve †Lvjv n‡q‡Q/†Lvjv
n‡e, Zvi m~Î a‡i Avwg Rbve /†eMg _________________________________________________________
wcZv/¯^vgx ___________________________________________________________________________
gvZv ___________________________________________________________) †K wb¤^wjwLZ Kvh©vejx
Avgvi c¶ n‡Z Kivi R‡b¨ KZ©„Z¡ I `vwqZ¡ w`jvg|
1| eZ©gvb wVKvbv (bwgbx) ____________________________________________________________
____________________________________________________________
‡Uwj‡dvb b¤^i (hw` _v‡K) _________________________________________________________
2| ¯’vqx wVKvbv (bwgbx) _____________________________________________________________
_____________________________________________________________
3| bwgbxi mv‡_ wnmveavixi m¤úK© _____________________________________________________
wZwb evsiv‡`kx bvMwiK Ges Zvi mwn wb‡gœ cÖ`Ë n‡jv, ˆe‡`wkK gy`ªv wbqš¿Y AvBbvbyhvqx Avgvi D³ wnmv‡e †jb‡`b
Kivi ¶gZv †`qv n‡jv| we‡klZt wb‡gœv³ KvR¸wj Ki‡ebt-
(1) K) bwgbx †h †Kvb mg‡q DB_Wªqv‡ji gva¨‡g ˆe‡`wkK gy`ªvi mgcwigvY evsjv‡`kx UvKv D‡Ëjb Ki‡Z
cvi‡eb|
L) Avg`vbx Kivi cviwg‡Ui `iLv¯— Ki‡eb Ges Zvnv †Wwjfvix wb‡eb|
M) AvMvg B‡¤úvU© cviwgU Bm¨y Kivi Rb¨ e¨vs‡K Avgvi ˆe‡`wkK gy`ªvi wnmve †WweU (weKjb) Kivi KZ©„Z¡
w`‡Z cvi‡eb|
N) Bb‡Wvm©‡g‡›Ui gva¨‡g D³ AvMvg B‡¤úvU© cviwgU n¯’vš—i Ki‡Z cvi‡eb Ges cÖ‡qvR‡b AvBbvbyqvqx Gi
Dci †h †Kvb ai‡Yi Kvh© Ki‡Z cvi‡eb|
O) AvMvg B‡¤úvU© cviwgU mv‡iÛv‡ii gva¨‡g B‡¤úvU© jvB‡mÝ Gi Rb¨ Av‡e`b Ki‡Z cvi‡eb Ges jvB‡mÝ
dig mwn Ki‡Z I MÖnY Ki‡Z Ges D³ jvB‡mÝ Gi gva¨‡g ÓFYcÎÓ Bmy¨ Ki‡Z cvi‡eb|
(2) K) GB wnmve n‡Z †h †Kvb As‡Ki UvKv Avgvi ev bwgbx we‡`‡k ågY D‡Ï‡k¨ ˆe‡`wkK gy`ªv wbqš¿Y AvBb
Abyhvqx D‡Ëvjb Ki‡Z cvi‡eb|
L) wbw`©ó AvBb †gvZv‡eK D³ wnmve n‡Z c„w_exi †h †Kvb †`‡k UvKv †cÖiY Ki‡Z cvi‡eb|
M) D³ wnmv‡ei UvKv wj‡qb ev e܇Ki gva¨‡g e¨vsK nB‡Z FY wb‡Z cvi‡eb Ges GZ‡`¨‡Ï‡k¨ e¨vs‡Ki
mwnZ cÖ‡qvRbxq `wjj cÎvw` m¤úv`b Ki‡Z cvi‡eb|
(3) WªvdU, †PK A_ev Ab¨ wb‡`©kvejx mg~n, wej Ae G·‡PÄ, cÖwgRwi †bvU A_ev Ab¨ wb‡Mvwk‡qej Bb÷y‡g›U
mg~n A_ev wiwmU mg~n Avwg /Avgvi c¶ n‡Z Zv‡K Bb‡Wvm© Kivi ¶gZv cÖ`vb Kijvg|
D³ ¶gZvcÖvß e¨w³ hw` e¨vs‡Ki Kv‡Q †Kvb A_© †`bv _v‡K A_ev Avgvi c¶ n‡Z KR© MÖnY K‡i _v‡K †m KR© ev
†`bv e¨vs‡Ki mvaviY Kvh© c×wZi Aš—M©Z ‡nvK ev bv †nvK Avwg Dnvi R‡b¨ `vqx _vKe| hw` Dnv bwgbxi †Kvb ΓwU
(Default) A_ev Ae‡njv A_ev RvwjqvwZi Kvi‡YI nq Avwg Dnvi Rb¨ `vqx _vKe|
Dc‡iv³ ¶gZv ZZw`b ch©š— ejer _vK‡e hZw`b ch©š— Avwg Avcbv‡K wjwLZfv‡e GB ¶gZvcÎ evwZj bv Kwi Ges
GZ`msµvš— wPwV Avcbvi Kv‡Q bv †cuŠQvq|

Avcbvi wek¦¯—
(L) (K)
bwgbxi bgybv ¯^v¶i) (GKvD›U †nvìv‡ii ¯^v¶i)
Dc‡iv³ ¯^v¶i mZ¨vwqZ Kwijvg

(K)
(GKvD›U †nvìvi) e¨e¯’vcK
d-110 ‡mvbvjx e¨vsK wjwg‡UW wnmv‡ei cÖK„wZ.........................
kvLv b¤^it

wnmveavixi ‡hŠ_ ‡hŠ_

÷¨v¤ú mvBR wnmveavixi wnmveavixi
÷¨v¤ú mvBR ÷¨v¤ú mvBR
Qwe
Qwe Qwe

wnmveavix e¨w³/cÖwZôv‡bi bvgt

wnmve cwiPvjbvKvixi bvg ¯^v¶i

wb‡`©kvejx (hw` _v‡K) Aby‡gvw`Z Kg©KZ©vi ¯^v¶i I mxj