CENTRAL KYC REGISTRY I Know Your Customer (KYC) Application Form

. Individual

fr-------------~----~----------------~'-----------_,--------------~------------~
Application Type

Account Type

Personal Details
New

New
0 Update
0 Update
0
D ,
KYC Nurnber

NcNumber

Prefix First Name Middle Name Last Name Photo

Name
(Same as 10 Proof)"
~jderlNa.ne·----+-----~------------------+-------------+---------------~
(if any)
Father/Spouse
Name"
Mother Name"

~=~~~l======~~~_~~_~~~~====~
I-
'Date of I OfT .
Birth" -] I _. ~ -~ Place
~.

countrY
Sign

(ddirnm/yyyyU _ Birth _ _ _ _.... of Birth = __j

.
!' Mal~D
Gender·
Female D Transgender D
I Marital Status"
Married D
Unmarried t:J r-:==.:===========:::::
I
. Indian CJ
J Nationality·
Other ..

rResidential Status" Resident Individual DNo" Resident'lndian 0 Foreign National 0 Person of Indian Origin D
1
occupation..
,__ •
Private s,eci;--a- Public Sector
~Pr;.;;o.;.;fe;.;;.ss,;;.;io.;;..r..;;la;;..1
__;:=~S.e~l;;.,f
B- Go~emment Sect~r
E;;;;;m..;.;p..,;l;;.Jo~edRetired
'8 Business
Student
0
0
Housewife
Other
D
..

8_._-_.
Type of Occupation
--------~--f-------.
_. ---
.
----------.--------.--.
Name & Address of Employer
.
Doctor DC.A.
-..;.-_;;;;~.~----..;;;;=--~
'--_._----_ .._--------_._-----'
...;;.,__
0
-
Advocate

A,DDJTIONAL·DETf.lILS REQUI'RED (If applicant Is resident outside India fC,H' Tax Purpose)
{Please read guidelines I details for jurisdiction of Residence and Tax Identification Number)
r,1
Engineer 0 Agricultural 0 Gold Busi'ness 0

ISO-3166 cou,;t;y'Code of .Jl,lrisdiction

Residence"l _.:__. I Place/City of Birth. .----r-......:..-------,--,
lax Identification Number of.. . . =--1IS0.3166 Country Code of
L!9uivalent (If Issued by ,Iurisdictj(')~) .~ Birth" _
PROOF OF IDENTITY (POI) (0118 Certified co£y_of anyone of the following proof of Identity needs to be submitted)
~AN .• ~(Aadhaa~
GA-Job Card I
jV2!er ID ca rd
umber
-- Passport. Expiry Date
,
. Driving Lie ense Driving license Exp. Date
-
Others (an y document notified by the Central Government)
L,
PROOF OF ADDRESS (POA) • PERMANENT I CURRENT' OVERSEAS ADDRESS DETAILS
(One Certified copy of any.one of the following proof of Address needs to be submitted)
-oter tD Card -- 1 UfD (Aadhaar)
ass port Number " NREGA Job Card
~
Driving License Others

IA ddress tine 1 iI·

~ ------_.
ddress Line :2
ddress Line 3
!!ylTownNiltage Pin Code
ISO-3166 Country Name/Code
~state I U.T.
CORRESPONDENCE I LOCAL ADDRESS DETAILS (In case the PoA Is not the local address or. address where the customer is
Currently residing To be declared only and no PoA is required) (In case of multiple correspondence/Local address, Please fiU "Annexur~ Ai")
o SAME AS PERMANENT ADDRESS I CURRENT I OVERSEAS ADDRESS - Otherwise Fill following
Address Line 1
Address line 2
_.Address Line 3
CityrrownNillage I Pin Code I
State / U.T. : 150-3166 Co~ntry Name/Code I
ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT
(If Applicant is resident outside India for Tax Purposes)
Same As Permanent Address o Same As Correspondence Address o Other wise Fill Following
Address Line 1
Address Line 2
Address Line 3
CityfTownMllage Pin Code
State / U.T. 150-3166 Country Name/Code -
CONTACTDETAILS (Communication will be done on.provlded Mobile No. and Email·ID)(Telephoneno. with STDCode)
Tel. (Office) - Tel. (Res) - Mobile
Fax - EmiallD

DETAILS OF RELATED PERSON (In case of additional related person, Please fill "Annexure 81" form)

Addition of Related Person D I Deletion of Related Person I0 I KYC Number

(If available)
1
Related Person Type Guardian of Minor
Beneficial Owner
o
o Nominee
Beneficiory
'8 Assignee 0 Authorized Representative 0
Name (Full Name)

PROOFOF IDENTITY(POI) *(One Certified copy of anyone of the following proof of Identity needs to be submitted)
PAN UID (Aadhaar)
Voter 10 Card NREGA Job Card
Passport Number
. Passport Expiry Date
Driving License Driving License Exp Date
Others (any document notified by the Central Government)

OTHER DETAILS
Income Range {Yearl:tl Below 1 Lac 0 1 L~c To 5 LacsO 5 Lacs To 15 Lacsp 15 Lacs To 25 LacsO Above 25lacsO
Net Worth (In INR) Rs ......................................................... As On Date ................................
Education I Qualification Below ~SC 0 SSC 0 HSC o Graduate 0 Master DegreeD Professional (CA, CS, CMA}_D
Please tick if Applicable Politically Exposed Person o Related to Politically Exposed Person 0
OTHER DETAILS (Relation with our Bank I Other Bank)
Our Bank Alc Details Other Bank Ale Details
AlcType Alc Number Bank Name Branch AlcType Ale Number
" ,

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APPLICANT DECLARATION Attestation J For Office Use only (Branch) Institutional Details
I hereby declare that the details furnished above are true and Name
correct to the best of my/Our Knowledge and belief and I Documents Received Risk Category
undertake 10 inform you of any changes therein. immediately.
In case any of the above information is found to be false for o Self Certified o High
untrue or misleading or misrepresenting. I am/we are aware o True Copies o Medium
that I/We may be held liable for it
I would like to share my personal/
KYC Registry
KYC details with Central o Notary o l.ow Code

Emp. No ...............................
Name .................................... Stamp
Signature / thumb Impression of Applicant Verified by Signature Designation .........................

Instruction: (1) Fields Marked with (*) are mandatory fields. (2) Please fill the form in English and in Block
Letters (3) Please read guidelines I detailed instructions 0 erleaf (4) List of Two character ISO·3166 country
codes are available overleaf.
------------------------------------------------------------------
For Bank Use Only (Entry I Authorisation purpose)
o Create o Update Customer 10 :
Entered By Authorised By Entered for CKYCR Authorised for CKYCR

Sign with Emp, t~ameI Number Stamp Sign with Emp. Name I Number Stamp Sign with Emp. Name I Number Stamp Sign with Emp. Name I Number Stamp