PRELIMINARY CREDIT FACILITY APPLICATION FORM

• Fields marked with *are mandatory fields. • Form to be filled in English and BLOCK letters with black pen only

Application Form No: 666

________________
NC001983519
Date:__________________________
09-09-2022

Application Type* New Update(Y) Update(N) KYC Number (Mandatory for KYC update request)

Account Type* Normal Simplified e-KYC through OTP Product Type* New Car Used Car

*Please select: MUDRA Stand Up India (If applicable)

Applicant
PERSONAL DETAILS OF THE APPLICANT(S) - FOR INDIVIDUALS AND SOLE PROPRIETORSHIP

Prefix First Name Middle Name Last Name

MR NAVNITBHAI GORDHANBHAI PATEL
Name (Same as ID proof)*
Maiden Name(If any*)
Father Name* GORDHANBHAI
Mother Name* SHAKARIBEN
Spouse Name* BHARATIBEN
Gender* Male Female Transgender Marital Status* Unmarried Married Other Date of Birth* 25-02-1972
Citizenship* IN-Indian Others(ISO 3166 Country Code) XXXX-XXXX-3782
UID(Aadhaar) No. Nationality______________
Residential Status* (If other than India)
Resident Individual Non Resident Indian Foreign National Person of Indian Origin
Academic Qualification* Under Graduate Graduate/Diploma Holder Post Graduate Professional
Category* General Scheduled Caste (SC) Scheduled Tribes (ST) Most Backward (MBC) Other Backward (OBC)
Religion* Hindu Muslim Sikh Zoroastrian Christian Buddhist Jain Others

PAN No. of Applicant* AXNPP9571H OR Form 60 Declaration* (to be filled in by those who do not have PAN)

PAN of Spouse AXNPP9571H Person with Disability UPI No.______________ Gas Utility No._____________
Date of Birth of Spouse 02-05-1975

DOCUMENT FOR PROOF OF IDENTITY (POI)* & PROOF OF ADDRESS (POA)*

(Certified copy of any one of the following Document to be submitted)
Document Name Document Number Document Expiry Date Proof of Identity Proof of Address
(PoI) (PoA)
A - Passport Number

B - Voter ID Card

C - Pan Card

D - Driving License

E - UID(Aadhaar) XXXX-XXXX-3782

F - NREGA Job Card

Z - Others

S - Simplified Measures
Account
Document Type Code:

Current Residential Line 1* A 1 VARDHMANNAGAR KARANNAGAR ROAD KADI

Address*
Line 2* KADI
Line 3* TA KADI DIST MAHESANA
Landmark* KARANNAGAR ROAD
City/Town/Village* MEHSANA
District* MEHSANA State/U.T GUJARAT ISO 3166 Country Code* INDIA
Pin/Post Code* 382715 State* Code*
GUJARAT
STD Code* Tel* Mobile* 9879873089

MR NAVNITBHAI GORDHANBHAI PATEL

09-09-2022 14:09:23
 Residence Ownership Type* Owned Rented With Parents With Relatives/Friends Others (Please Specify)________________
No of years at above residence: 10.0
Type of Residence Bunglow Row House Flat Others (Please Specify)____________________
Year(s) at Current Address_____________
Perment Residential Line 1* A 1 VARDHMANNAGAR KARANNAGAR ROAD KADI
Address* Line 2* KADI
Line 3* TA KADI DIST MAHESANA
Landmark* KARANNAGAR ROAD
City/Town/Village* MEHSANA
District* MEHSANA State/U.T Code* GUJARAT ISO 3166 Country Code* INDIA
Pin/Post Code* 382715 State* GUJARAT
STD Code* Tel* Mobile* 9879873089

Correspondence/Local Address: Current Residential Address Permanent Residential Address

E-mail ID (Personal)*________________________________________________________________________________________________________
mylovegudiya21@gmail.com 1

OCCUPATIONAL DETAILS

Occupation Type* S-Service --> Private Sector Public Sector Government Sector
0-Others --> Professional Self Employed Retired Housewife Student X-Not Categorised
E-mail ID (official)*______________________________________________________________________________________________________

Employer Details Proprietorship Partnership Pvt. Ltd. Public Sector Goverment Multinational Others (Please Specify)_________
Type of Profession Doctor CA/CS Architect Lawyer Consultant Engineer Others (Please Specify) AGRICULTURIST
Designation OTHER Department Agriculture
Director Identification Number(DIN)
Employee ID (mandatory if salaried) No.of year(s) in current job* 16.0 Total Experience(No. of years) Job 16.0
/Businees
Net Annual Income*________________________________________
300000 No of years in Previous job*____________________________________________
0.0
Income from other sources:
________________________________________ Gross Annual Income*____________________________________________
300000
________________________________________ Income From Agriculture: ____________________________________________
Constitution HUF Section 25 Company Govt. Body/Statutory Body Limited Liability Partnership
Others Others (Please Specify)
OTHER - Salaried/ Pensioner/ Retired/
Nature of Business Manufacturing Trading Services Agriculture Student/ Rental income/ Housewife etc.
Provident Fund No ________________________________________ Date of Incorporation
Company Name* NAVNEETBHAI PATEL
Company Address* A1 VARDHMANNAGAR
City/Town/Village* Landmark* KARANNAGAR ROAD
District* MEHSANA State/U.T Code* GUJARAT ISO 3166 Country Code* INDIA
Pin/Post code* 382715 State* GUJARAT
STD Code* Tel.* Extn Mobile*

DETAILS OF THE APPLICANT(S) - (NON INDIVIDUAL)

Name*

Date of Incorporation
Constitution HUF Section 25 Company Govt. Body/Statutory Body Limited Liability Partnership
Others Others (Please Specify)
Nature of Business Manufacturing Trading Services Retailing Agriculture Stock Broker Real Estate
Whether the MSME unit is ZED rated Yes No _________If Yes Bronze Silver Gold Diamond Platinum
Tax Identification Number (TIN)
Legal Entity Identifier (LEI)
MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23
 Corporate Identity Number (CIN)

PAN No. of Applicant PAN No. of Co Applicant

Company Email ID ____________________________ OR Form 60 Declaration (to be filled in by those who do not have PAN
Name of other partners/trustees/directors/adult members of the HUF:
Name Nationality Address

Principle Office/
Regd. Office Address: PIN Landmark State Fax:
Factory / Branch or local
Office Address
PIN Landmark State Fax:
Ownership and Control Name of the Entity:
Structure Information: Name (Mr/Mrs/Ms/Dr

(Application for authorised Signatories, Partners Directors, Trustees)

1. Date of Birth Nationality* Indian Others (pls Specify)
2. Type of Identity Proof 3. Identity Proof number
Residential Address
City
PIN State
Designation

Occupation Details* Salaried Self Employed Others (Please Specify)______________

Others (Please Specify)
Type of Profession Doctor CA/CS/ICWA Architect Lawyer Consultant Engineer

No. of years in previous business*

No. of years in current business* Industry Type Gross annual Turnover

Gross Annual Income* Net Annual Income*
Income from Agriculture* Income from other Sources
2

PREFERRED MAILING ADDRESS

• Preferred Mailing Address: Office Current Residence Permanent Residence

GST

1. GST Yes No

2. Beneficiery of GST Benefit Applicant or Co-applicant State GUJARAT

3. Applicant / Co-applicant's GST registration number -

4. Is applicant a Related Party to ICICI Bank? Yes or No

(a) If Yes please Specify relation - Staff Group Company / Subsidiary company

EXISTING RELATIONSHIP WITH ICICI GROUP

Bank A/c No Bank A/c No Bank A/c No

DECLARATION FOR REPAYMENT FROM NEW SAVINGS/CURRENT ACCOUNT

Type of Account: Savings Current

Account in name of:
I hereby declare and consent to open an account with ICICI Bank and provide repayment from the new account. I further give my
express consent to ICICI Bank and its authorised personnel to contract me in person, via phone, sms or e-mail for the purpose and in
relation to activation of this account. MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23
 REFERENCE DETAILS

1.Name HARDIK PATEL 2.Name VISHNU PRAJAPATI

Address KADI,,, Address KADI,,,

Pin 382715 Tel 9687640358 Pin 382715 Tel 9978859401

Relationship Friend Relationship Friend
Email ID Email ID
DETAILS OF PRODUCT (TO BE PURCHASED AGAINST WHICH IS CREDIT FACILITY IS CREDIT FACILITY IS REQUIRED) AND
CREDIT FACILITY
• Product is for Personal Use Commercial use (please tick the right option)
1. Product Description:____________________________________________________________________________
MARUTI SUZUKI INDIA LTD Eeco 5 STR WITH A/C+HTR CNG
2. Manufacturer/Seller/Dealer:___________________________________________________________________________
MARUTI SUZUKI INDIA LTD
3. Model No./Version___________________________
Eeco 4. Sub Model No./Version____________________________
5 STR WITH A/C+HTR CNG
5. Product New Used If used, year of manufacture:
condition
6. Product is: To be purchased Already owned by the Applicant (please select)
7. Invoice/Valuation amount:Rs.________________________
(Where Product is to be purchased using the Credit Facility)
• Credit Facility Amount:Rs. 370000
• *Tenure of the Credit Facility: 60
8. Fixed Interest Rate. 8.55%
9. Description Amount in Rs. Description Amount in Rs.
Valuations charges (used car)< Rs. 800/- Stamp Duty Charges collected in
addition to processing fees
Documentation charges Rs. 550/- Processing fees 5500.0

Registration Certificate charges Rs. 450/- GST on Processing fees

Information Utility Charges (only for Rs. 300/-
corporate cases)
Note : 1. Taxes, other government levies etc will be applicable as per prevaling rates in addition.
2. The charges will be deducted from the loan amount at the time disbursement.
3. Fees and charges as stated above are a one-time non-refundable amount and are collected by ICICI Bank for the
purpose of appraising the Application and the same are independent of outcome/result of such appraisal.

• I/We authorize ICICI Bank to debit the charges as mentioned in point 9 from the disbursal amount
OTHER DETAILS

1. Purpose of the Loan:*

Working Capital Asset Purchase-Original Investment Asset Purchase enhancement Agricultural & Allied activites New Vehicle Purchase
Used Vehicle Purchase Business Utilisation District MEHSANA Utilisation Taluka KADI
Division AGRICULTURE & RELATED : SERVICE ACTIVITIES :
:Sub Division AGRICULTURE & RELATED SERVICE ACTIVITIES
: 2. Type of Industry*

SSI Village Industries Cottage Industries RTO SRTWO KVI Industrial Estate SHG Micro Credit NGO Tiny Sector Small Scale

Service & Business Enterprise Ship breaking Handloom Co-operatives Retail Trade Software Industry Aerated water/soft drinks Small Business Farming

Transportation of Agricultural & allied products/commodities/passengers Technical assistance to food processing Biscuits/Confectionery Packaging for food processing Others

3. Agri Land Details:*

Acreage of land holding____________
acres (1hectare = 2.5 acres) (Landholding should be reported in acres)
Landless Labours Tenant Farmers Share Cropppers Others
DECLARATION FOR SUBMISSION OF DOCUMENTS IN ELECTRONIC FORM
I / We confirm and agree that the below listed documents have been submitted to ICICI Bank and its authorised representative in electronic form via smart phone / tablet /
other electronic modes
Photograph Proof of Identity Proof of Address Relationship Proof Income Proof Bank / Loan Account Statement Others

CONSENT FOR ICICI BANK

1. ICICI Bank Limited ("ICICIBank") would like to use your personal details in the application form/registration form from time to time to send you marketing information
to inform you about products, services or promotional offers that are offered by ICICI Bank on its own and in collaboration or through tie-ups with partners/third parties. By
opting into the following methods of communication, you confirm that ICICI Bank may contact you for these purposesin one or more of the following ways:

By Post By Email By WhatsApp By Social Media By SMS/Text By Telephone/Call

Yes to marketing by all of the above No to marketing by all of the above
2. ICICI Bank would like to share your personal details in the application form/registration form with its group entities/partners of ICICI Bank so that the group entities
/partners of ICICI Bank may from time to time send you marketing information to inform you about the products, services or promotional offers that are offered by the group
entities/partners in collaboration with ICICI Bank. By giving your preference below you either allow or disallow ICICI Bank to share your personal details in the application
form/registration page: MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23
 Yes, I would like ICICI Bank group companies to contact me Yes, I would like Partners of ICICI Bank to contact me No for both
You can proactively opt-out of this any time or update your preferences by visiting our branches or by calling at Please also see our privacy notice for more information in
relation to how we collect and use your personal information https://www.icicibank.com/nri-banking/RHStemp/privacy-notice-eu-users.page

MOST IMPORTANT TERMS & CONDITIONS AND DECLARATIONS BY CUSTOMER

A) Common Declaration 1.) I/We declare that all the particulars and information and details given/filled in this application form are true, correct, complete
and up-to-date in all respects and that I/We have not withheld any Information whatsoever, I/We understand that certain particulars given by me/us are
required by the operational guidelines governing banking companies. 2.) I/we confirm that no insolvency proceedings or suits for recovery of outstanding
dues or monies whosoever or for attachment of my/our assets or properties and/or any criminal proceedings have been initiated and/or are pending against
me/us and that I/We have never been adjudicated insolvent by any court or other authority. 3.) No action nor other steps have been taken or legal
proceedings started or against me/us in any court of law/other authorities for winding up, dissolution, administration or re-organization or for the
appointment of a receiver, administrative receiver, trustee or similar officer or for my/our assets. 4.) I/We authorize ICICI Bank Limited (ICICI Bank) to
exchange, share or part with all the information and details relating to my/our existing loans and/or repayment history to other ICICI group companies,
banks, financial institutions, credit bureau, agencies, statutory bodies etc. and maybe required or as they may deem fit and shall not hold ICICI Bank (or any
of its group companies or its/their agents/representatives) liable for use/sharing of this information. 5.) I/We understand and acknowledge that ICICI Bank
shall have the absolute discretion, without assigning any reasons (unless required by applicable law), to reject my/our application and that ICICI Bank shall
not be responsible/liable in any manner whatsoever to me/us for such rejection or any delay in notifying my/us of such rejection and any costs, losses,
damages or expenses, or other consequences, caused by reason of such rejection, or any delay in notifying me/us of such rejection, of our application. 6.)
ICICI Bank Limited/its Group Companies reserves the right to retain the photographs and documents submitted with the photo-card application and will not
return the same to the applicant. 7.) Except to the extent disclosed to ICICI Bank, no director or a relative/near relation (as specified by RBI) of a director of
a banking company (including ICICI Bank) of a relative/near relation (as specified by RBI) of a senior officer of ICICI Bank (as specified by RBI) is a
partner of our concern, or a trustee, member, director, manager, employee of our concern, or of our subsidiary, or our holding company, or a guarantor on
my/our behalf, or holds substantial interest in our concern or my/our subsidiary or holding company. 8). I authorized ICICI Bank and its representatives to
call me or SMS me with reference to my application. This consent will override any registration or DNC/NDNC 9.) Request for loan cancellation if any
post disbursement of loan should be within 45 days.
B) Central KYC Declaration :1) hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake
to inform you of arty changes therein, immediately 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. 2.) I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above
registered number/email address.

Name and signature of the Applicant:

MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23

In case of partnership/HUF/association of persons: For and on behalf of______________________________

________________________________________it each of following partners/members of Name and signature:

the firm/HUF/association:___________________________________________________________________

In case of company/society/trust: For and on behalf of_____________________________________________

________________________________________________________________________________________ Name of the Authorised Signatory:

Designation:_________________________Date:____________________Place:______________________

SOURCING DETAILS

Sourcing Channel: Branch DDSA DSA Online Alternate DST

RM Name & ID:____________________________________________
356434-Amrut Mali-356434 Retainer Code: ____________________________________________
IPRO005079Z04373-SOLANKI S MAGANBHAI

Branch Name :________________________________________________________________________________________________________

KADI
Branch Sol ID:_____________________________________________________
0442 CRM Lead ID:___________________________________

DSA Name & Broker Code:_____________________________________________________________________________________________

288415-KRUNAL FINANCIAL SERVICES

Dealer Sales Executive Code (Name & Code):______________________________________________________________________________

DMTNA00001-NOT APPLICABLE

Promotion scheme:_____________________________________________________________________________________________________
MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23
 ATTESTATION / FOR OFFICE USE ONLY

Documents Received Certified Copies

KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

Date: 09-09-2022 13:47:17 Name: ICICI BANK LIMITED

Emp. Name: AMRUT MALI Code: IN144

Emp. Code: 356434

Emp. Designation: RM
Emp. Branch:
[Institution Stamp]
[Employee Signature!]
AMRUT MALI
09-09-2022 13:47:17

I do hereby confirm that I have met with Applicant/Authorized Signatory in person at his/her residence and confirm that
I have verified the copies of documents (as applicable) against original as produced by the applicant. I also confirm that
Applicant(s) have signed the application form in my presence.
MR NAVNITBHAI GORDHANBHAI PATEL
09-09-2022 14:09:23