CKYC & KRA KYC Form

Know Your Cihent (KYC) Appihcathon New

type*
Appihcathon Form (For hndhvhduaiis oniy)
☐ Update KYC number*
• Pieaise fii tte form hn Engihist and hn BLOCK ______________________________________________________________________________________________________________________________________________________

ietteris
• Fheidis marked whtt ‘*’ are mandatory KYC type* Normai (PAN his mandatory) ☐ PAN exempt hnveistoris (Refer
hnistructhonis K)

1. Identhty detahiis (Pieaise refer hnistructhon A at tte end)

PAN BAOPJ2579N
____________________________________________________________________________________________________________________________________________________________________________________
Pieaise encioise a duiy atteisted copy of your PAN card

Prefx Fhrist Name Mhddie Name Laist Name

Name* (isame ais ID proof) Mr

____________________
JAYAKUMAR
____________________________________________________________________________________________________________________________________
DHANDAPANI
___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Mahden Name (If any) ____________________ ____________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________

Fatter’is/Spouise’is Name* Mr
____________________
DHANDAPANI
____________________________________________________________________________________________________________________________________
M
___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Motter’is Name* Mris

____________________
ESWARI
____________________________________________________________________________________________________________________________________
D
___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Date of bhrtt (DD MM YYYY)* 08

_______________
06
_______________
1993
______________________________

Gender* M - Maie F - Femaie T PHOTO

-Tranisgend
er

Marhtai Marrhed Unmarrhed Otter

istatuis*

Chthzenisthp IN - Indhan ☐ Otteris - Country

* Country: code:
_______________________________________________________________________________ ______________________________

Reishdenth Reishdent Non-reishdent

ai istatuis* hndhvhduai Indhan

☐ Forehgn ☐ Perison of
Nathonai Indhan orhghn

Occupath Prhvate Pubihc isector Govt. Profeisishonai

on type* isector isector

X - Not Seif empioyed Rethred Houisewhfe Studen

categorhised t

2. Proof of Identhty (PoI)* (For PAN exempt hnveistor or hf PAN card copy not provhded) (Pieaise refer hnistructhon C & K at tte end)

(Certified copy of any one of the following Proof of Identity [PoI] needs to be submitted)

☐ A - Paisisport number _________________________________________________________________________________________________________________________________

Paisisport exphry date _______________ _______________ ______________________________

☐ B - Voter ID card ________________________________________________________________________________________________________________________________

☐ D - Drhvhng ihcenise Drhvhng ihcenise exphry

date
_________________________________________________________________________________________________________________________________ _______________ _______________ ______________________________

E - Aadtaar card Signed by: JAYAKUMAR DHANDAPANI

☐ _________________________________________________________________________________________________________________________________

eSigned using Aadhaar (digio.in)

Date: 2021-02-17 10:30:37 IST
☐ F - NREGA job card _________________________________________________________________________________________________________________________________

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 ☐ Z - Otteris (A) [any document nothfed by tte centrai ________________________________________________________________________________________________________________________________
Identhfcathon number ________________________________________________________________________________________________________________________

government]

Otteris (B) [Refer hnistructhon C (3)] ________________________________________________________________________________________________________________________________

Identhfcathon number _______________________________________________________________________________________________________________________

3. Proof of Addreisis (PoA)*

3.1 Current/Permanent/Overiseais addreisis detahiis (Pieaise isee hnistructhon D at tte end)

Address

Lhne 1* S/O: Dtandapanh, 4/245,, VALASUPALAYAM, J.krhistnapuram,, Cohmbatore, , Tamhi Nadu, 641671
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 2
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 3 Chty/Town/Vhiiage Cohmbatore

*
_________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________

Dhistrhct Zhp/poist 641671 State/UT code TN ais per Indhan Motor Vethcie
code* Act, 1988
____________________________________________________________________________________________________ _____________

________________________________________________________________________________________________________

State/UT* TAMIL NADU

________________________________________________________________________________________________________
Country Indha
____________________________________________________________________________________________________
Country code IN
_____________
ais per ISO 3166

Addreisis type* Reishdenthai/Buishneisis ☐ Reishdenthai ☐ Buishneisis ☐ Reghistered ofce ☐ Unispechfed

(Certified copy of any one of the following Proof of Address [PoA] needs to be submitted)

Paisisport number Paisisport exphry date _______________ _______________ ______________________________

_________________________________________________________________________________________________________________________________

Voter ID card
_________________________________________________________________________________________________________________________________

Drhvhng ihcenise Drhvhng ihcenise exphry

date
_______________ _______________ ______________________________

_________________________________________________________________________________________________________________________________

Aadtaar card XXXXXXXXXXXX

_________________________________________________________________________________________________________________________________

NREGA job card _________________________________________________________________________________________________________________________________

Otteris (A) [any document nothfed by tte centrai Identhfcathon number

government]
_________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Otteris (B) [Refer hnistructhon D (3)] _________________________________________________________________________________________________________________________________

Identhfcathon number ________________________________________________________________________________________________________________________

3.2 Correispondence/Locai addreisis detahiis* (Pieaise isee hnistructhon E at tte end)

Same ais Current/Permanent/Overiseais addreisis detahiis (hn caise of muithpie correispondence/iocai addreisiseis, pieaise fii ‘Annexure A1’, isubmht reievant
documentary proof)

Lhne 1* SAME AS ABOVE

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 2 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 3 _____________________________________________________________________________________________________________________________________________________________________________________
Chty/Town/Vhiiage* _________________________________________________________________________________________________________________________________________________

Dhistrhct ________________________________________________________________________________________________________
Zhp/poist ____________________________________________________________________________________________________
State/UT code _____________
ais per Indhan Motor Vethcie
code* Act, 1988

State/UT* ________________________________________________________________________________________________________
Country ____________________________________________________________________________________________________
Country code _____________
ais per ISO 3166

4. Contact detahiis (Aii communhcathon whii be isent on provhded mobhie number/emahi ID) (Pieaise refer hnistructhon F at tte end)

Emahi ID jkumarispd@gmahi.com
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mobhie +91 9894375850 Tei. (Ofce) Tei. (Reishdence)

number
____________ ____________________________________________________________________________________________ _____________________________ __________________________________________________________________________________________ _____________________________ __________________________________________________________________________________________

Signed by: JAYAKUMAR DHANDAPANI

eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST

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 5. FATCA/CRS hnformathon (Thck hf appihcabie) ☐ Reishdence for tax purpoiseis hn Jurhisdhcthon(is) outishde Indha (Pieaise refer hnistructhon B at tte
end)

Addhthonai detahiis requhred* (Mandatory oniy hf above opthon 5 his thcked)

Country of jurhisdhcthon of Country code of jurhisdhcthon of reishdence ais per ISO 3166
reishdence
__________________________________________________________________________________________________________________________________ _____________

Tax hdenthfcathon number or equhvaient (hf hisisued by

jurhisdhcthon)*
_____________________________________________________________________________________________________________________________________________________________________________________

Piace/Chty of bhrtt* Country of Country code ais per ISO 3166

bhrtt*
________________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________

Addreisis

Lhne 1* _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 2 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lhne 3 _____________________________________________________________________________________________________________________________________________________________________________________
Chty/Town/Vhiiage _________________________________________________________________________________________________________________________________________________

State/UT* ________________________________________________________________________________________________________
Zhp/poist ____________________________________________________________________________________________________
State/UT code _____________
ais per Indhan Motor Vethcie Act,
code* 1988

Country ________________________________________________________________________________________________________
Country code ______________
ais per ISO 3166

6. Detahiis of Reiated Perison (Opthonai) (Pieaise refer hnistructhon G at tte end) (hn caise of addhthonai reiated perisonis, pieaise fii ‘Annexure B1’)

☐ Addhthon of reiated perison ☐ Deiethon of reiated perison KYC number of reiated perison (hf
avahiabie*)
___________________________________________________________________________________________________________________________________________________________________

Reiated perison type* ☐ Guardhan of mhnor ☐ Aisishgnee ☐ Auttorhzed repreisentathve

Prefx Fhrist Name Mhddie Name Laist Name

Name* ____________________ ____________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________

(If KYC number and name are provhded, beiow detahiis of isecthon 6 are opthonai)

☐ Proof of Identhty [PoI] of reiated perison* (Pieaise refer hnistructhon H at tte end)

(Certified copy of any one of the following Proof of Identity [PoI] needs to be submitted)

☐ A - Paisisport number _________________________________________________________________________________________________________________________________________

Paisisport exphry date _______________ _______________ ______________________________

☐ B - Voter ID card _________________________________________________________________________________________________________________________________________

☐ D - Drhvhng ihcenise Drhvhng ihcenise exphry

date
_________________________________________________________________________________________________________________________________________ _______________ _______________ ______________________________

☐ E - Aadtaar card _________________________________________________________________________________________________________________________________________

☐ F - NREGA job card _________________________________________________________________________________________________________________________________________

☐ Z - Otteris [any document nothfed by tte centrai Identhfcathon number

government]
_________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

7. Remarkis (hf any)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signed by: JAYAKUMAR DHANDAPANI

eSigned using Aadhaar (digio.in)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date: 2021-02-17 10:30:37 IST

19
8. Appihcant deciarathon

• I tereby deciare ttat tte detahiis furnhisted above are true and correct to tte beist of my knowiedge
and beihef and I undertake to hnform you of any ctangeis tterehn, hmmedhateiy. In caise any of tte
above hnformathon his found to be faiise or untrue or mhisieadhng or mhisrepreisenthng, I am aware ttat I
may be teid ihabie for ht. I tereby deciare ttat I am not makhng tthis appihcathon for tte purpoise of
contraventhon of any Act, Ruieis, Reguiathonis or any istatute of ieghisiathon or any
nothfcathonis/dhrecthonis hisisued by any governmentai or istatutory auttorhty from thme to thme.

• I tereby conisent to recehvhng hnformathon from Centrai KYC Reghistry ttrougt SMS/Emahi on tte
above reghistered number/emahi addreisis.

Name of appihcant : JAYAKUMAR DHANDAPANI

Pan: BAOPJ2579N

Date 17
_______________
02
_______________
2021
______________________________
Piace BANGALORE, KARNATAKA
______________________________________________________________________________________________________________________________
Shgnature or ttumb hmpreisishon of appihcant

9. Atteistathon/For ofce uise oniy

Documentis recehved Certhfed copheis

KYC hn-perison verhfcathon (IPV) carrhed out by (Refer hnistructhon J) Inisthtuthon detahiis

Date 17
_______________
02
_______________
2021
______________________________
Name NEXTBILLION TECHNOLOGY PRIVATE LIMITED
__________________________________________________________________________________________________________________________________________________________________________

Emp. name Azgar Aih

___________________________________________________________________________________________________________________________________________________________________________
Code IN3893
__________________________________________________________________________________________________________________________________________________________________________

Emp. code NBT193

___________________________________________________________________________________________________________________________________________________________________________
Emp. branct BANGALORE
__________________________________________________________________________________________________________________________________________________________________________

Emp. Deishgnathon Cuistomer Succeisis Executhve

___________________________________________________________________________________________________________________________________________________________________________

Locathon BANGALORE

[Inisthtuthon istamp]

Signed by: JAYAKUMAR DHANDAPANI

eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST

20
 Signed by: JAYAKUMAR DHANDAPANI
eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST

Sign here

Name of appihcant: JAYAKUMAR DHANDAPANI

Pan: BAOPJ2579N

21
 Signed by: JAYAKUMAR DHANDAPANI
eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST

Sign here

Name of appihcant: JAYAKUMAR DHANDAPANI

Pan: BAOPJ2579N

22
 Signed by: JAYAKUMAR DHANDAPANI
eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST

Sign here

Name of appihcant: JAYAKUMAR DHANDAPANI

Pan: BAOPJ2579N

23
Name on the Appaicant: JAYAKUMAR DHANDAPANI
Signed by: JAYAKUMAR DHANDAPANI
eSigned using Aadhaar (digio.in)
Date: 2021-02-17 10:30:37 IST
Pan: BAOPJ2579N

Sign here

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