PERSONAL LOAN Application No.

: DPBAN1210190172951

Sourcing Branch Name: CLIX_BANGALURU

APPLICATION FORM Sourcing Branch Code: CLIX_BANGA

Please use BLACK or BLUE INK and CAPITAL LETTERS while filing the form. All fields in "*" are MANDATORY.

PERSONAL DETAILS

Salutation* Mr. Ms. Mrs. Dr.

Full Name* SEELAM NARAMMAGARI YATHEENDRA NATH
Citizenship v Indian Foreign National
CKYC Number (If any) Latest passport
size picture
Mother’s Name* VARALAKSHMI SEELAM
of applicant
Father's/ Spouse Full Name* CHENDRAYUDU SEELAM NARAMMAGARI
Gender* v Male Female Others
Date of Birth* 03061992
D D M M Y Y Y Y
Qualification Graduate Undergraduate Postgraduate Others
Marital Status v Single Married Ot hers
Aadhaar No.* 000000008672 PAN No.* JHNPS2430D
Proof of Address* Passport NREGA Job Card Driving Licence Aadhaar Voter ID Others
Already a Clix Customer? Please provide your Clix loan ID

CONTACT DETAILS

Current Address*
Address* OLD NO. 46/1, NEW NO. 883, 1ST FLOOR, 5TH MAIN ROAD,
TULASI THEATRE ROAD, CHOWDESHWARI LAYOUT, MARATHAHALLI
Landmark
City* BANGALORE
State* Karnataka Pin Code* 560037
Mobile No.* (+91) 9121505555 Alternate Mobile No. (+91)*
Phone No. (with STD Code)
E-mail ID (Personal)* snyatheendranath@gmail.com
Current Residence Owned Family Rented Company Leased
Period of Stay Y Y M M If Rented, Monthly Rent

Permanent Address*
Same as Current Address Yes No
Address* H NO 14/398-7-2-B SAI NATHAPURAM, KADAPA ROAD MYDUKUR,
YSR DISTRICT
Landmark
City* KADAPA
State* Andhra Pradesh Pin Code* 516172
Mobile No.* (+91) Alternate Mobile No. (+91)* 9121505555
Phone No. (with STD Code)
E-mail ID (Personal)*
Preferred Mailling Address Residence Office E-mail

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Clix Capital Services Pvt. Ltd., E- 20, 1 Floor, Hauz Khas, New Delhi - 110016, India
 OCCUPATION DETAILS
Occupation Category V Salary Self Employed Others’
If Salaried* Central/ State Govt. Public. Ltd. Pvt. Ltd. Proprietor/ Partnership Others’
Employer Name CAPGEMINI TECHNOLOGY SERVICES INDIA LIMITED
Designation
Office Address* DIVYASREE TECHNOPARK IT SEZ KUNDALAHALLI
WHITEFIELD BANGALORE
Landmark -
City* BANGALORE
State* Karnataka Pincode* 560037
Phone No. (with STD Code) Ext. -
Email ID (Official) yatheendranath.seelam@capgemini.com
Current Work Experience Y Y M M Total Work Experience 0Y Y M
48 M Net Income (Salary Slips) ` 57705 Lakhs P.a.
If Business Trader Manufacturer Wholesaler Service provider Others
If Professional Doctor CA/ CWA/ CS Architect Lawyer Others
Date of Commencement of D D M M Y Y Y Y
Business/ Profession
If self Employed-Office Type Owned Rented
Address* Current Permanent Office
Registered with GST Yes No If Yes, GSTIN
Any existing Loan (monthly EMI in `)

LOAN REQUIREMENTS AND BANK DETAILS

Loan Amount* (`) 300000 Tenure* 48 Months
Purpose Home Buy/ Renovation Marriage Travel Education Business Expansion
Consumer Durable Others (please specify)
Loan Outstanding (consolidated) ` Current Monthly EMIs (`)

Disbursement Mode
Bank Name KOTAK MAHINDRA BANK LIMITED
Account Type v Savings Current Overdraft
Account No. 4712976356
IFSC Code KKBK0008066
Loan Repayment Mode ECS/ NACH Post dated Cheque Salary Deduction

REFERENCES
REFERENCE 1 REFERENCE 2
Full Name

Mobile No. (+91) (+91)

Address
Relationship with Applicant

DOCUMENTS SUBMITTED
Proof of Identity Proof of Residence Bank Statement
Any other document/s as requested by Clix for loan processing
Note: Aadhaar and Pan Card are mandatory to be submitted.

HELP US KNOW YOU BETTER

1. Do you own a two wheeler? Yes No 2. What is the last 4 digit of registration number?
3. What refrigerator do you own? Big Small Not own 4. What mobile phone brand do you own?
5. When did you last change your mobile phone?

st
Clix Capital Services Pvt. Ltd., E- 20, 1 Floor, Hauz Khas, New Delhi - 110016, India
 DECLARATION
1. Clix Capital, its agents / representatives may provide information on various products, offers and services provided by Clix / its group companies for purpose of cross-sell
through any mode (including without limitation through telephone calls / SMSs / emails). Please select if you wish to avail the services.
Yes No
2. I hereby state & undertake that I have no objection in authenticating myself with Aadhaar based authentication system and hereby give my consent to provide my
Aadhaar number, Biometric and/or One Time Pin (OTP) data for Aadhaar based authentication for the purposes of availing of facility from Clix Capital Services Private
Limited and/or its affiliates and/or any person acting on its behalf. I understand that the Demographic details (name, DOB, gender, address and photograph) and/or
Biometrics and/or OTP I provide for authentication shall be used only for authenticating my identity through the Aadhaar Authentication system and for obtaining my
E kyc details along with my email ID/mobile number (if provided) from UIDAI for completing this specific transaction and for no other purposes. I understand that Clix
Capital Services Private Limited shall ensure security and confidentiality of my personal identity data provided for the purpose of Aadhaar based authentication.
Yes No
B. DECLARATIONS
3. The Applicant(s) declares that he/she is an Indian resident and that all the information and details given/ filled in this Application Form are true, correct, valid and up-to
date.
4. The Applicant agrees that the application shall form of the Facility documents if the loan is approved. Further, that Clix Capital reserves the right to reject the loan
application and I/ we shall hold Clix Capital responsible / liable in any manner.
5. The rate of interest and duration need not be standardized. It could vary for different customers depending on any one or a combination of the above factors. The rate of
interest also varies depending upon relative credit strengths of borrowers. Final applicable interest rate is based on various other parameters and communicated in the
sanction letter / loan agreement. The Applicant(s) have perused, understood and agreed to Clix’s Approach of determining rates, processing and other charges for the
Facility which is also available at the website of the company www.clix.capital under section pricing policy
6. This Application Form has been duly and validly executed by the Applicant(s).
7. The Applicant authorises Clix Capital and/or any person acting on its behalf to access and collect information/ data from credit bureau agencies for purpose of
evaluating and processing my loan application. I/we undertake that (i) CIBIL and any other agency so authorised may use, process the said information and data
disclosed by Clix Capital ; and (ii) CIBIL and any other agency so authorised may furnish the processed information and data prepared thereof to banks/financial
institutions, as may be specified by the Reserve Bank in this behalf; (iii) Clix Capital shall use, process, store the information and data disclosed for granting the current
loan or any other loan in the future and/ or such other manner as maybe permissible.
8. The Applicant agrees that for Aadhaar authentication through OTP, I hereby declare that no other account has been opened nor will be opened using Aadhaar OTP
based KYC either with Clix Capital or with any other entity regulated by RBI. Further, I hereby agree to complete my full KYC by visiting the nearest branch of Clix Capital
or by requesting a visit from the Clix Capital’s representative and providing such representative with biometric details within 12 months of opening such account.
9. The Applicant understands that Clix Capital shall ensure security and confidentiality of the data and information submitted herein. In the event that the loan application
stands rejected the Applicant may request for return of the data/ information within 30 days, failing which Clix Capital shall retain or destroy the information.
10. The Applicant agrees that the monies received pursuant to grant of the loan shall not be utilized for any unlawful purpose including but not limited to investment in
capital market and speculative purposes.
11. The Applicant declares that there is pending litigation whether in the nature of civil, criminal or bankruptcy that shall adversely impact the Applicant/s ability to repay the
loan, if granted.
12. The Applicant agrees that any discounts/ commissions or pricing of any asset/equipment is purely an offer of the manufacturer, that no claim shall lie against Clix
Capital for such offer/discount. Clix Capital shall not be held responsible in any manner for the same.

Date: D D M M Y Y Y Y

Place: Applicant Signature

Clix Capital Services Pvt. Ltd., E- 20, 1st Floor, Hauz Khas, New Delhi - 110016, India

ACKNOWLEDGEMENT TO BE RETAINED BY THE APPLICANT

Clix Capital Services Private Limited

(Formerly Known as GE Money Financial Services Pvt. Limited
901B, 9th Floor, Two Horizon Centre, DLF Phase-V, Gurgaon 122002
Customer Care Contact Details Tel +91 124 4545965/ +91 124 3812400
Email: hello@clix.capital I Web : www.clix.capital

Credit at the sole discretion of Clix. This is a preprinted acknowledgment and does not require any signature. Please visit http://www.clix.capital for detailed fees and
charges under the respective loan product.

Applicant Name _______________________________________________________________ Loan Amount Requested ___________________________________________________

Application No. ________________________________________________________________ Date ________________________________________________________________________

Processing Fee % ________________________________________________________________ Interest Rate % P.a. _________________________________________________________

Sales representative ID ________________________________________________________ Representative Mobile _____________________________ Place______________________________

We shall communicate the decision on your application within 21 working days.

Credit at the sole discretion of Clix Capital Services Private Limited. This is a preprinted acknowledgment and does not require any signature.
The rate of interest and duration need not to be standardized. It could vary for different customers. Some of the key factors and gradations of risk that impact
interest rates are nature of financing, term, market reputation, risk rating, historical credit performance, length of relationship etc. The rate of interest also varies
depending upon relative credit strengths of financing. Schedule of other charges also mentioned in the application form and can be referred by the borrower on the
Clix website (www.clix.capital) under section Pricing Policy.
 Clix Capital Services Private Limited (Formerly known as GE Money Financial Services Private Limited)
Corporate Office: 901B, 9th Floor, Two Horizon Center, DLF Phase 5, Sector 43, Gurugram, Haryana 122002
st
Registered Office: E- 20, 1 Floor, Hauz Khas, New Delhi - 110016, India
Ph: +91 124 3302000 | E-mail: hello@clix.capital