Know Your Customer (KYC) Form for CHA

- Individuals -

Name:
Mr/Mrs/Ms

Date of Birth Sex

Present Address: Please paste a

most recent
Photograph

PAN Number
Aadhar No: Mobile
Telephone Email

Permanent Address:

Telephone Mobile
Fax Email

NOTE: Attested Photo copies of Mentioned ID Proof Documents: PAN/UID/Passport/Voter ID/Driving License
Connections:
1). BSNL:
2). AIR TEL :
3). TATA SKY:
4). RFID TAGS:

1) CAR NO: 2). CAR REGISTRATION NO:

2) CAR NO: 2). CAR REGISTRATION NO:

1) BIKE NO: 2). BIKE REGISTRATION NO:

2) BIKE NO: 2). BIKE REGISTRATION NO:

Declaration:
I hereby declare that the information provided in this form is accurate and complete. I confirm that any information
is found incorrect and/or incomplete that leads a violation of regulations may initiate legal actions, and I accept that
I am the responsible party for any and all charges, penalties and violations.

Name & Signature of the Authorised Signatory Date: ___________ (dd/mm/yyyy)