MobiKwik Wallet KYC Form

Please fill in BLOCK letters. One Mobikwik Systems Private Limited

1 Wallet Details

Phone number linked with Wallet

Email ID linked with Wallet

2 Identity Details (as per ID Proof)

Name

Please affix recent

Date of Birth D D M M Y Y Y Y Gender Male Female passport sized photo
graph.

ID Proof Submitted (should have photograph)

PAN Card (recommended) Aadhar Card Driving License Passport

Voter ID NREGA Job Card Government Issued ID Proof

Cross sign the photograph

3 Address Details (as per Address Proof)

Flat No. / Plot No. / House No. / Building / Area

City/District

State PIN Code

Address Proof Submitted (Bank Statement/Utility Bills should not be more than 2 months old)

Aadhar Card Bank Statement Driving License Voter ID Passport

Utility Bills Pension Payment NREGA Job Card Municipal Tax Receipt

4 Declaration

I hereby declare that the above furnished details are true to the best of my knowledge. In case any of the above information is found to be
false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

Place Date Signature

5 For Office Use Only

Documents verified against originals Agency Name

Photos Collected Self-attest verified Seal/Stamp of Verifying Agency

Agent Name