CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | individual Important intructions: 10 Pt nce wih ar mandy fis 10) Paae tha omin Ergin ani BLOCK iets. (0) Peseta n DOAMYY oat O) Pee rend acon wt eld gies hat etons ) Uist Slate U code a per indian Motor Vehicle Act. 1088s avaliable at tne end F) Ustof wo character 150 3108 county codes is evalabe at the en. () KY numberof appicant is mandatory for ude apptcatin. H) For parca seclon upd, pleat ck (nthe box avaliable before the secon ruber and se off the sections nt requied to be updated. attend For office use only Applicaton Typet Mew CHU (Tote fad byfancalisivion) KYCNumber 12) BHI 5 BI7/B14101) 2.3 4 (Mandatory for KYC update request) ‘Account Type" —G/Normal__[) Simplified (for low risk customers) [) Small T14. PERSONAL DETAILS (Pease referinsiucton A at the end) Pret Frat Name ce Name Last Nome C0 Name* (same 810 pen vir]. JIOLHIN DOE i Maiden Name any) yrs WLE X DOE Father/Spouse Name iris) MARK DOE Mother Name* My¥s) (RElE NA DoE Date of Bith* O1-oF- 14a} PHOTO Gender UA Male COF-Femele C1 T-Transgender Marta Status* janied DUnmanied others Citizenship* oa Indian Others (ISO 3166 Country Code, ) Residential Status Resident individual (Non Resident indian O Foreign National CiPerson of indian Origin Occupation Type Di S-Service ( (Private Sector CiPublle Sector Government Sector) D0-Others ( 1) Professional Cisetf Employed C)Retired ClHousewife (]Student) (A-Business: 1X Not Categorised (2. Tick IF APPLICABLE [JRESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Pease refer nstucion B atthe end) ‘ADDITIONAL DETAILS REQUIRED" (Mandatory ony ft secton 28 cked) 10 3166 Country Code of Jursditon of Resience* e ‘Tax Identication Number or equivalent (issued by tacetony” (2/3 jp SLT 8 IOL2L. Place /Ciy of itn = AUISIT]R ALTA |) 180.8106 Country Code ot Btn 5 [3. PROOF OF IDENTITY (Poly" (Pease refer insirucion Cathe end) (Cortes copy ot anyone othe flowing root of Identiy/Po) needs fo be submited) & A-Passport Number FBIT|Z Passport Expy Date ol -oln- aoe CB Voter 1D Card OC PaNCard ee Diving Licence Expiry Date | — 1 E- UID (Aadhaar) mt F-NREGA Job Card | Bal DZ Others (any socurent noted bythe canal goverment 1 | ||| || | |) AXentitcation Number | 2 S-Simplifed Measures Account - Document Type code | 'entfcation Number | ‘ 4. PROOF OF ADDRESS (PoA)* (1.4.1 CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS (Please see insructon D athe end) (Contited copy ofan cas othe following Poot of Address [PoA] needs fo be submit) ‘Address Type" _-‘CJResidential ‘Business Residential, Business Registered fice Clunspeciiod Proof of Address* Passport CD Driving Licence UID (Aadhaar) voter identty Cars CONREGA Job card) others i Simpied Measures Account - Document Type code Uae Tale sneer TT TTT TTT TI ttt [ITT TEtit tr | ety Towns vitager @ WER TYUTOP Pin/ PostCode" 1/251ii3~ (> Stale/UTCode* D2) 180 3166 Country Code* | 3