DRAFT SPECIMEN

ABC BANK
FINANCIAL INCLUSION ACCOUNT OPENING FORM
No._______________ Date: ________
Name of the Branch
Village / Town
Sub District / Block
Name
District
State
SSA Code / Ward
No.
Village Code / Town
Code
as !er census "#$$%
Name of
Village/Town
as !er census
"#$$%
Applicant Details:
Full Name &r./&rs./&s. ''''''''''''' ''''''''''''' '''''''''
(irst &iddle )ast Name
Marital Status Gender & / (
Name of
Father /
Souse
Address
Pin Code
Telehone !
Mo"ile No#
Date of Birth
DD/MM/$EAR
Aadhaar / EID
No#
PAN No#
MNREGA %&B
CARD N&
&''uation /
Profession
Annual In'ome
No# of
Deendents
Detail of
Assets
*wning +ouse , -/N *wning (arm , -/N
No. of Animals , An. other ,
Existin !an" A#c.
o$ $a%il& %e%'e(s #
)o*se)ol+
- / N /f .es0 No. of A/cs. ''''''''''
,isan C(e+it Ca(+ Whether 1ligible - / N
/ re2uest .ou to issue me a Rua( Card.
I also understand that I am eligible for an O-e(+(a$t after satisfactory operation of my account after 6 months of
opening my account with a Limit of Rs.2000/- (Rupees wo housand only! for meeting my emergency" family
needs sub#ect to the condition that only one member from the household will be eligible for o$erdraft facility. I
shall abide by the terms and conditions stipulated by the %an& in this regard.
Declaration
I hereby apply for opening of a %an& 'ccount. I declare that the information pro$ided by me in this application
form is true and correct. he terms and conditions applicable ha$e been read o$er and e(plained to me and
ha$e understood the same. I shall abide by all the terms and conditions as may be in force from time to time. I
declare that I ha$e not a$ailed any )$erdraft or *redit facility from any other ban&.
Pla'e)
Date) Si*nature / +TI of Ali'ant
Nomination,
I .ant to no%inate as *n+e(
+ame of
+ominee
Relationship 'ge Date of %irth in
case of minor
,erson authorised in case to recei$e the amount
of deposit on behalf of the nominee in the e$ent
of my "minor(s! death.
3To be ca!tured
through s.stem or
obtain latest
!hotogra!h not older
than si4 month5
Pla'e)
Date) Si*nature / +TI of Ali'ant