Name & Signature of the Authorised Signatory

Date : D D M M Y Y Y Y Seal/Stamp of the intermediary

1. Name of the applicant

2. Father’s / Husband’s Name

3. a) Gender

PHOTOGRAPH

Please affixyour recent passport

size photograph

A. IDENTITY DETAILS

ANNEXURE - J

PART I - KNOW YOUR CLIENT (KYC) APPLICATION FORM (For Individuals)46, Avenue 4, Street No. 1, Banjara Hills, Hyderabad - 500 034, Telangana State.

Please fill this form in ENGLISH and in BLOCK LETTERS

Male

Femaleb) Marital Status

Single

Marriedc) Date of Birth

4. a) Nationality Indian

Other(Please specify _______________________________________________)

a) StatusResident Individual

Non Resident

Foreign National

5. a) PAN b) Aadhaar Number, if any

6. Specify the proof of identity submitted PAN card

Any other (Please specify): ________________________________

1. Residence/ Correspondence Address

B. ADDRESS DETAILS

City/Town/Village

State

PIN Code

Country

2. Specify the proof of address submitted for Residence/ correspondence address

3. Contact DetailsTel (off.)

Fax No.

Email ID

Tel (res.)

Mobile No.

4. Registered Address (if different above Mandatory for Non- Resident Applicant to specify overseas address)

City/Town/Village

State

PIN Code

Country

Correspondence Address Residence Address

C. DECLARATIONI 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 any 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.

Date D D M M Y Y Y Y

Sr. No. Particulars

Originals verified and Self-Attested Document copies received

In-Person-Verification (IPV) details:

a) Name of the person doing IPV

b) Designation

c) Name of Organization

d) Signature

e) Date

FOR OFFICE USE ONLY

2

1

D D M M Y Y Y Y

FIRST HOLDER

Signature across Photograph

Signature of the Applicant ________________________________________________

Third Gender

New Change Request (Tick whichever is applicable)

OTHER DETAILS 1. Gross Annual Income Details : (Please specify) Income Range per annum

Below ` 1 Lac ` 1-5 Lac ` 5-10 Lac ` 10-25 Lac More than ` 25 Lacs

OR

Networth (Net worth should not be older than 1 year) Amount `_______________ as on (date)

2. Occupation : (Please tick any one and give brief details)

Private Sector Public Sector Government Service Business Professional Agriculturist Retired

Housewife Student Others (Please specify) _________________________________________________

3. Please tick, if applicable : Politically exposed Person (PER) Related to a Politically Exposed Person (PEP)

4. Any other Information _____________________________________________________________________________________

Date D D M M Y Y Y Y

X____________________ (Signature of 1st Holder)

CLIENT PROFILE

1. Educational Qualification

a. Illiterate b. Undergraduate c. Graduate d. Post Graduate e. Other

2. Number of Members in family