KRA KYC FORM

Account Opening Form (For Individuals Only) Know your Client (KYC) KYC Mode.: KRA Verified DigiLocker
Aadhar XML OVD Upload

Application No.: 9001986291

Please fill in ENGLISH and in BLOCK LETTERS
 A. Identity Details (please see guidelines overleaf)
1. Name of Applicant (As appearing in supporting identification document).
Name Sachin Kumar Sah
PHOTOGRAPH
Maiden Name (If any)
Father’s Name MAHESH LAL SAH Please affix
Spouse Name the recent passport
size photograph and
Mother’s Name
sign across it
2. Gender Male Female Transgender B. Marital status Single Married Others
C. Date of Birth 06/13/1982 3. Nationality Indian Other
4. Status Please tick (3 ) Resident Individual Non Resident Foreign National (Passport Copy Mandatory for NRIs & Foreign Nationals)
Person of Indian Origin
*5. PAN BJWPS6225D Please enclose a duly attested copy of your PAN Card
6. GST No. (Pls provide GST registration certificate)

 B. Address Details (please see guidelines overleaf)

1. Address for Correspondence
F 1, TOWER 13, TYPE 5 ,NEAR INA MARKET ,KIDWAI NAGAR EAST ,SOUTH WEST DELHI ,DELHI

City / Town / Village SOUTH WEST DELHI District SOUTH WEST DELHI Pin Code 110023
State DELHI Country INDIA
2. Contact Details
Tel. (Off.) (ISD) (STD) Tel. (Res.) (ISD) (STD)
Mobile (ISD) (STD) 9810728710 Fax (ISD) (STD)
Email ID sach_nes@rediffmail.com
I here by declare that the mobile number mentioned above belongs to: ✔ Self Spouse Dependent Parent Dependent Children
I here by declare that the Email ID mentioned above belongs to: ✔ Self Spouse Dependent Parent Dependent Children
3. Proof of address to be provided by applicant. Please submit ANY ONE of the following valid documents & tick (3 ) against the document attached
Passport UID (Aadhaar) Narega Job Card Driving License *Latest Gas Bill *Voter Identity Card *Latest Electricity Bill
*Latest Bank A/c Statement/Passbook *Latest Telephone Bill (only Land Line) Others (please specify)
* Not more thant 2 Months old. Validity/Expiry date of proof of address submitted
4. Permanent Address of Resident Applicant if different from above B1
F 1, TOWER 13, TYPE 5 ,NEAR INA MARKET ,KIDWAI NAGAR EAST ,SOUTH WEST DELHI ,DELHI

City / Town / Village SOUTH WEST DELHI District SOUTH WEST DELHI
Pin Code 110023
State DELHI Country INDIA
Permanent Address Type Residential / Business Residential Business Registered Office Unspecified
5. Proof of address to be provided by Applicant. Please tick ✔ UID (Aadhar).

 DECLARATION
I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I undertake to inform you of any changes therein,
immediately. In case any of the above information is found to be false or untrue, misleading or misrepresenting, I am/we are aware that I/we may be held liable for it. I/We hereby
consent to receiving information from CVL KRA through SMS/Email on the above registered number/Email address. I am/We are also aware that for Aadhar OVD based KYC, my
KYC request shall be validated against Aadhar details. I/We hereby consent to sharing my/our masked Aadhar card with redable QR code or my Aadhar XML/Digilocker XML file,
along with passcode and as applicable, with KRA and other Intermediaries with whom I have a business relationship for KYC purposes only.

Place SOUTH WEST DELHI Date 28-02-2024

SIGNATURE OF THE APPLICANT

Note:For the purpose of online account opening, KYC verification means checking of customers Live photo and verification of KYC documents.

ICICI Securities Ltd.

AADHAAR XML CONVERTED PDF

Name Sachin Kumar Sah

Gender M
Date of Birth 13-06-1982
Mobile
Email
Ref. Number 223537f533ef904a58a7d07f93952b3e7cc752a60a31
d5b144609d5d9313e3c4
Aadhaar No. xxxxxxxx3774
Address F-1, Tower-13, Type-5 ,Near INA Market ,Kidwai
Nagar East ,South West Delhi ,Delhi ,110023 ,India

Note: This document has been created from the UIDAI XML submitted by the Investor. Investor has
submitted this data with informed consent to ICICI Securities Ltd./ICICI Bank Ltd. as KYC proof for opening
ICICI Securities Trading and ICICI Bank Demat account.