xfn;fn}

lvlrPs ]f kmf6] ]f
kf|sl[ts JolQms ]f lxtuf|xL vftf vfN]g] lgjb]g
Recent Photo
-lwtfk]q sl]Gbo
| lgIfk] ;j]f ljlgodfjnL, @)^* s ]f ljlgod @) ;u
F ;DalGwt_

sfofn
{ o ko
| fh
] gsf nflu dfq

cfjb]g gDa/ M ldlt M

Application No : Date :
;s
+ t] gDa/ M zfvf M
Symbol No : Branch :

Please complete all details and strike out the non-applicable Field/boxes.
tn pNnl]vt ;Dk0' {f ljj/0f /fdf|;
] u
F eg{' kg5
{] . cfkm;
' u
F ;/fs
] f/ gePs ]f ljj/0f pNnv
] ug{] sf7]fdf t;
] f{] ws {f tflglbg' xfn
] f
DP ID Client ID
lxtuf|xL vftf gDa/ M
1 3 0 1 3 7 0 0

Vfftfs ]f lsl;d M JolQmut u/} cfjf;Lo gk]fnL ljbz

] L
Types of Account : Individual Non Resident Nepalese Foreigner

lxtuf|xLs ]f gfd M
Owner :
hGd ldlt la=;=+ D D M M Y Y Y Y
O={;=+ ln· k?
' if dlxnf
Date of Birth B.S A.D. D D M M Y Y Y Y
Gender Male Female
/fli6o
« tf gk]fnL cGo
Nationality Nepali Other
gful/stf g=+ hf/L u/s
] ]f lhNnf hf/L u/s
] ]f ldlt D D M M Y Y Y Y
Citizenship No. Issuance by District Date of Issuance
/fxbfgL g=+ hf/L u/s
] ]f :yfg hf/L u/s
] ]f ldlt D D M M Y Y Y Y
Passport No. Place of Issuance Date of Issuance:
kl/rokqs ]f lsl;d kl/rokq g=+
Types of Identity Card ID Card No.
hf/L ug{] lgsfo hf/L u/s
] ]f ldlt
D D M M Y Y Y Y
Issuing Authority Date of Issuance

kqfrf/ ug{] 7u
] fgf/ Correspondence Address
/fi6« M kb|z
] M
Country : State :
cr+n M lhNnf M Uff=lj=;=÷g=kf=÷d=g=kf=M
Zone : District : VDC/Municipality/Metropolitan:
6fn
] M j8f g=+ M Ans g=+ M
Tole : Ward No. : Block No.:
Telephone No. -6l]nkmfg
] = g=+_ Mobile No. -dfa]fOn
{ g=+_
Fax No. -kmo
\ fS; g=+_ Email -Odn
] _
:yfO{ 7u
] fgf/ Permanent Address :
/fi6« M kb|z
] M
Country : State :
cr+n M lhNnf M Uff=lj=;=÷g=kf=÷d=g=kf=M
Zone : District : VDC/Municipality/Metropolitan:
6fn
] M j8f g=+ M Ans g=+ M
Tole : Ward No. : Block No.:
Telephone No. -6l]nkmfg
] = g=+_ Mobile No. -dfa]fOn
{ g=+_
-kmo
Fax No. \ fS; g=+_ Email -Odn
] _
glhss ]f NofG8dfs{ M
Nearest Landmark :
 Psf3/ kl/jf/sf ;b:ox?s ]f ljj/0f / Details of Family Members (As Applicable)
aa'fs ]f gfd M
Father’s Name :
xh/' aa'fs ]f gfd M
Grand Father's Name :
cfdfs ]f gfd M
Mother’s Name :
klt÷kTgLs ]f gfd M
Spouse’s Name :
5f/]fs ]f gfd M
Son’s Name :
clajflxt 5f/]Ls ]f gfd M
Unmarried Daughter’s Name :
ax'f/Ls ]f gfd M
Daughter in-Law’s Name :
;;/'fs ]f gfd M
Father in Law’s Name :
kz
] fut ljj/0f M
Details of Occupation :

kz
] fut ljj/0f÷ Details of Occupation
;j]f ;/sf/L ;fjh{lgs lghL Ifq] Pg=hL=cf=]÷cfO={ Pg= hL= cf=] sfgg
' L lj1
kz
] fM Service Govt. Public/Private Sector NGO/INGO Legal Expert
Occupation : ljzi]f1 Jofkf/L ljwfy {L ;j]f lgjt[ ul[x0fL cGo
Expert Businessperson Student Retired House Wife Others

Jofkf/s ]f ks
| f/ M pTkfbg ;j]fdv
' L cGo
Types of Business : Manufacturing Service Oriented Others

;:+yfs ]f gfd M
Organization’s Name :
7u
] f gf M kb M
Address : Designation :
cfos ]f ;Ldf -jflifs
{ ljj/0f _ ÷Income Limit (Annual Details)
cflys
{ ljj/0f M ?= !,)),))) ;Dd ?= !,)),))! bl]v ?= @,)),))) ;Dd ?= @,)),))! bl]v ?= %,)),))) ;Dd
Financial Details : Upto Rs. 1,00,000 From Rs. 1,00,001 To Rs. 2,00,000 From Rs. 2,00,001 To Rs. 5,00,000

?= %,)),))) eGbf dfly

Above Rs. 5,00,000

lgIfk] ;b:on] lxtuf|xLs ]f vftfdf ePs ]f 36a9 :jrflnt ?kdf u/fpg] ÷ gu/fpg] Uf/fpg] gu/fpg]
Standing Instruction for the automatic transactions Yes NO
Vfftfs ]f ljj/0f kf|Kt ug{] bl}gs ;fKtflxs kflIfs dfl;s
Account Statement Daily Weekly 15 Days Monthly
d÷ xfdLn] lgIfk] ;b:o / lxtuf|xLs ]f s/f/gfdf, kr|lnt Pg] , lgod, ljlgod / ; ]f df ePs ]f ;z + fw]g dfGg dGh/' ub5 { ' ÷ ub5
{ }f . dfly
pNnl]vt lja/0f ;To tYo /xs ] ]f / ; ]f ljj/0fdf sg
' } km/s k/] sfgg' adfl]hd ;xn F' f, ae
' mn
'F f / lxtuf|xL vftf /2 ug{ dGh/' ub5 { ' ÷ub5
{ f.}
prevalent act, regulations, bylaws and any amendments on it. I/We hereby acknowledge that the above disclosed details are
true. I further hereby consent to borne any legal actions in case any false disclosure of information related to me/us and the
Depository Participants reserve right to close my account. All disputes are subject to the jurisdiction of courts in Kathmandu
Nepal.

lgjb]ss ]f gfd M
Right -bfo
F f_ Left -afo
F f_ Applicant’s Name :

x:tfIf/ M
Signature :

cf+7}f 5fk
Thumb Print
-x:tfIf/ ub {f sfn ]f d;Ls ]f ko
| fu
] ug{' kg5{]_
(Please use Black Ink.)
 ;/+Ifss ]f ljj/0f -gfafnss ]f xsdf dfq_ / Guardian’s Details ( In Case of Minor Only)
gfd ÷ y/ M
Name/ Surname :
lgjb]s;u
F s ]f ;DaGw M
Relationship with applicant:
kqfrf/ 7u
] fgf M
Correspondence Address :
/fi6« M kb|z
] M cr+n M lhNnf M
Country : State : Zone : District :
6l]nkmfg
] g=+M dfa]fOn
{ g=+ M ˆofS; g=+ M
Telephone No. : Mobile No. : Fax No. :
PAN No. -:yfoL nv
] f g=+_ M Email -Odn
] _M
- gfafnss ]f xsdf ;/+Ifs tyf gfafns ba's
} ]f kmf6] ]f ;n
+ Ug ug{' kg5
{] . _
( In case of Minor, guardian and minor’s photos are required to submit. )

Right -bfo
F f_ Left -afo
F f_
;/+Ifss ]f gfd M
Guardian’s Name :
;/+Ifss ]f kmf6] ]f
Guardian’s Photo x:tfIf/ M
Signature :

cf+7}f 5fk
Thumb Print

u/} cfjfl;o gk]fnLsf nflu / For Non Resident Nepalese

ab}l]zs 7u
] fgf M zx/ M
Foreign Address : City :
/fHo M bz
] M u/} cfjfl;o sf8] g=+ M
State: Country : NRN Code No. :

Right -bfo
F f_ Left -afo
F f_

lgjb]ssf] gfd M
Applicant’s Name :

x:tfIf/ M
Signature :
cf+7}f 5fk
Thumb Print

as
+} vftfs ]f ljj/0f / Bank Account Details
as
+} vftfs ]f lsl;d M art vftf rNtL vftf cGo
Types of Bank Account : Saving Account Current Account Others
as
+} vftf gDa/ M
Bank Account Number :
as
+} s ]f gfd M
Name of Bank :
zfvfs ]f gfd M
Name of Branch :
 OR5fOPs ]f AolQm ;DaGwL ljj/0f / Nominee’s Details
d/] ]f dT[o' ePs ]f cj:yf jf dn
} ] g;ss
] ]f cj:yfdf bx]fos ]f AolQmn] d/] ]f gfddf ePs ]f ;Dk0' {f lwtfk]qs ]f xsbfaL ug{ kfpg] 5 .
In the event of my death or incapacity, the following named nominee shall be entitled to the
balance of my Demat Account.
OR5fOPs ]f AolQms ]f gfd M
Name of Nominee M
lgjb]s;u
F s ]f ;DaGw M
Relationship :
gful/stf÷/fxbfgL gDa/ M hf/L 7fpF M pd/] M
Citizenship/ Passport No. : Place of Issue : Age :
/fi6« M kb|z
] M cr+n M lhNnf M
Country : State : Zone : District :
6l]nkmfg
] = g=+M dfa]fOn
{ g=+ M ˆofS; g=+ M
Telephone No. : Mobile No. : Fax No. :

PAN No. -:yfoL nv

] f g=+_ M Email -Odn
] _M

Right -bfo
F f_ Left -afo
F f_
OR5fOP{s ]f
JolQms ]f kmf6] ]f
OR5fOP{s ]f AolQms ]f gfd M
Nominee ’s Photo Name of Nominee :

x:tfIf/ M
Signature :
cf+7}f 5fk
Thumb Print

3/ /xs
] ]f :yfgs ]f gSzf Site Map of the Account Holder’s Residence

N
p

From main Road Street ………..................................................................................the distance of the Residence is …….......................................

Meters (Approximately)

lgjb]s ]f gfd M
Name of Applicant :

x:tfIf/ M
Signature :
 -cws
{ §L_

DP ID Client ID
lxtuf|xL vftf gDa/ M
1 3 0 1 3 7 0 0

lxtuf|xLs ]f ljj/0f

gfd M
Name :

cflwsf/Ls x:tfIf/ M
Authorized Signature :

al'emlnPs ]f /l;b
Receipt
cfjb]g g=+ M ldlt M
Application No.: Date :

xfdLn] vftf vfN]g kmf/d al'emlnof+} .

We received account opening form

lxtuf|xLs ]f gfd M

Pg cfO{ ;L Plzof Soflk6n lnld68] dfk{mt

Pg cfO{ ;L Plzof as
+} lnld68]
NIC ASIA Bank Limited

lgIfk] ;b:os ]f gfd M

Depository Participant’s Name :
b:tvt M
Signature :
sDkgLs ]f 5fk M
Company’s Stamp :