21/07/2021 KYC Form

A. Identity Details

1. Name of the Applicant

First Name Last Name

2. Fathe 's/Spouse's Name

First Name Last Name

2a. Gender

Male

Female

2b. Ma ital Status

Single

Ma ied

2c. Date of Bi th

MM-DD-YYYY

Date

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3. Nationality
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21/07/2021 KYC Form

Please Select

4. Status

Resident Individual

Non Resident

Foreign National

5. PAN

6. Proof of Identity Submitted for PAN Exempt Cases

UID

Passpo t

Voter ID

D iving License

Other

B. Address Details

1. Address for Co respondence

Street Address

Street Address Line 2

City State / Province

Please
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21/07/2021 KYC Form
Postal / Zip Code Count y

2. Phone Number

(000) 000-0000

Please enter a valid phone number.

3. Email

example@example.com

4. Proof of Address to be Provided by Applicant

Passpo t Ration Card

D iving License Voter Identity Card

Registered Lease/Sale Agreement of Latest Bank Account
Residence Statement/Passbook
Latest Telephone Bill Latest Elect icity Bill

Latest Gas Bill Other

5. Pe manent Address of Resident Applicant If Different From B1 Above

Street Address

Street Address Line 2

City State / Province

Please Select

Postal / Zip Code Count y

6. Proof of Address to be Provided by Applicant

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21/07/2021 KYC Form

Passpo t Ration Card

D iving License Voter Identity Card

Registered Lease/Sale Agreement of Latest Bank Account
Residence Statement/Passbook
Latest Telephone Bill Latest Elect icity Bill

Latest Gas Bill Other

C. File Upload
Please upload related photographs and documents.

Browse Files
Drag and drop files here

D. Declaration

I hereby declare that the info mation provided in this fo m is accurate and complete. I
confi m that any info mation is found inco rect and/or incomplete that leads a
violation of regulations may initiate legal actions, and I accept that I am the
responsible pa ty for any and all charges, penalties and violations.

Name of the Applicant

First Name Last Name

Signature of the Applicant

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21/07/2021 KYC Form

Clear

Date Signed

07-21-2021

Date

Submit

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