Unified

Credit Card Customer Application Form

Application No.: 96000282990

Personal Details:

Full Name Date Of Birth Gender

SAYAN SARKAR 31-03-1995 MALE

Phone Number A lternate Contact PA N Number

Number
+91 9046514455 FROP S7645H
- Not Available

Email ID Religion Marital Status

SAYAN.RANBIR@ GMAIL.C O - Not Available SINGLE

M

Permanent A ddress Communication A ddress Office A ddress

DEBALAY DEBALAY AMBIKANAGAR . - Not Available

AMBIKANAGAR,.,PASHC HIM PASHC HIMPARA NORTH 24
PARA,. NORTH 24 PARGANAS 743424 WEST
PARGANAS 743424 WEST BENGAL (WB) IN
BENGAL (WB) IN

Is Your Permanent Designation Mother's Maiden Name

A ddress Same A s
JUNIOR MANAGEMENT - Not Available
Communication A ddress?

- Not Available

Father's Name Spouse Name Current Employer

- Not Available - Not Available - Not Available

Monthly Take Home Office Email ID Qualification

Salary
- Not Available - Not Available
Rs.- Not Available/-

Purpose Of Facility A dd-On Product

- Not Available - Not Applicable

Employee ID A adhar No/Proof of Employment Type

Identity
- Not Applicable - Not Available
ADC RD/-ADC RD
Customer Category Citizenship Residential Status

- Not Available Indian Resident Individual

Facility Usage:

Utilisation District Division Sub Division

NORTH 24 PARGANAS P ERSONAL LOANS AND P ERSONAL LOANS AND

C ONSUMER LOANS C ONSUMER LOANS

A ctivity

OTHER P ERSONAL LOANS -

OTHER THAN TO STAFF

Additional Details:

Place/City Of Birth* Occupation Gross A nnual Income

- Not Available SALARIED - Not Available

Declaration Nominee First Name Nominee Last Name

- Not Available - Not Available - Not Available

Nominee DOB Experience Education

- Not Available - Not Available - Not Available

Company Type Department

OTHERS - Not Available

Profession Do You Have A ny Existing Relationship A ccount

Relationship With ICICI? Number
- Not Available
Yes - Not Available

A re You A Relationship Have you been assisted

Director/Relative Of by an ICICI
- Not Available
Director Of ICICI Bank or Representtive?
A ny Other Bank?
- Not Available
- Not Available

Branch ID A uto Debit Required A uto Debit A ccount

Number
- Not Available - Not Available
- Not Available

Mailing A ddress Debit Type

- Not Available - Not Available

 I confirm that the communication address is as mentioned in the online application
form. I also authorise ICICI Bank to send all correspondence to the mentioned
communication address and shall indemnify ICICI Bank for any loss/ damage/ liability
due to updation of the communication address provided by me during the account
opening journey.

FATCA Declaration

I am Tax Resident of ONLY India (This information is required to be collected as per The Income Tax
Act, 1961 to comply with FATCA and CRS regulations. We will continue to report the above
information 'As Is' till we receive any change request from you)