VER 3-01/2018 Appl No.

APPLICANT
Affix Recent
Passport Size
Colour Photograph of
Co-applicant / Guarantor

CO-APPLICANT
With Signature across

CENTRAL KYC REGISTRY Know Your Customer (KYC) Application Form Individual
For office use only Application Type New Update
(To be filled by financial institution)
KYC Number (Mandatory for KYC update request)

Account Type Normal Simplified (for low risk customers) Small

GENERAL
CO-APPLICANT/GUARANTOR DETAILS
PERSONAL DETAILS
Name : P R E F I X F I R S T M I D D L E L A S T

Maiden Name (If any):

DECLARATION
Mother’s Name :
Father’s Name:
Spouse Name:
Date of Birth : Gender: M / F / TG Person with Disabilities : Yes No

UID(Aadhaar No.) : Category: General SC ST OBC MBC Others

PAN : Marital Status: Single Married Other
Form 49A Form 60/61 Number of Dependents: Children Others

PMAY
Religion : Hindu Muslim
Sikh Christian Buddhist Jainism Others
Residential Status : Resident Indian Non-Resident Indian PIO OCI
Current Residence : Owned Company Provided Rented Others(specify)
Qualification : Below SSC SSC Under Graduate Graduate PG Professional
Relationship with Applicant :

INSURANCE
Nationality, Citizenship : IN-INDIAN Others (ISO 3166 Country code )
if other than Indian :
CURRENT / COMMUNICATION ADDRESS
Address same as Applicant Yes No (If no, please fill below)
Address 1 :
Address 2 :

CREDIT CARD
Address 3 :
Address 4 :
Landmark : City :
District : Pin Code:
State : Residing since : Years Months
Telephone No.: STD/ISD Code: (R) Mobile No.:
SAVINGS A/C / OVERDRAFT

Email ID :

PERMANENT/REGISTERED ADDRESS
Same as Current / Communication Address Yes No (If no, please fill below)
Address 1 :
Address 2 :
Address 3 :
Address 4 :
Landmark : City :
District : Pin Code:
CURRENT A/C

State : Residing since : Years Months

Telephone No.: STD/ISD Code: (R) Mobile No.:

1
VER 3-01/2018 Appl No.

OCCUPATION/BUSINESS DETAILS
Salaried
Company Type : Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector Manufacturing
Government Others
Occupation Type : S-Service ( Private Sector Public Sector GOVT Sector) Others
Work Experience : YY MM Gross Annual Income `
Company Name:
Department : Division: Sub-Division:
Designation : Employee No.:
Spouse Working : Yes No If yes, monthly income `

Self Employed,
a) In Business : Manufacturing Trading Services Retailing Agriculture Stock Broker
Real Estate Shroff/Money Lender
b) Professional: Doctor CA/CS Lawyer Architect Consultant Engineer Others
c) If Others: Housewife Retired Student Pensioner
d) If Agri. Allied / Farmer, Nil <= 5 acres >5 acres
Details of landholding:
No of yrs in business : YY MM Annual Sales Turnover `
ROC No Dt of Incorporation
Company Name:
Office Address:
Landmark :
City : State:
PIN : STD/ISD Code: (O) Extn No.:
Oficial email ID :
Preferred Mailing Address: Office Address Current / Communication Address Permanent / Registered Address
TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA
ADDITIONAL DETAILS REQUIRED
ISO 3166 Country Code of Jurisdiction of Residence

Tax Identification Number or equivalent (If issued by jurisdiction)

Place / City of Birth* ISO 3166 Country Code of Birth

PROOF OF IDENTITY
(Certified Copy of any one of the following Proof of Identity needs to be submitted)
A-Passport Number Passport Expiry Date D D M M Y Y Y Y
B-Voter ID Card
C-PAN Card
D-Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E-UID (Aadhaar)

F-NREGA Job Card

Identification
Z-Others (any document notified by the central government) Number

S-Simplified Measures Account - Document Type code Identification

Number
PROOF OF ADDRESS

CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS

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

Address Type Residential / Business Residential Business Registered Office Unspecified

Proof of Address Passport Driving Licence UID (Aadhaar)
Voter Identify Card NREGA job Card Others P l e a s e S p e c i f y

Simplified Measures Account-Document Type code

2
 VER 3-01/2018 Appl No.
GENERAL DETAILS
DETAILS OF BANK ACCOUNTS

1.. Name
Name of
of Account
Account Holder P R E F I X F I R S T M I D D L E L A S T

Name of Bank Branch

Account Number Current Savings Banking Since Years

2.. Name
Name of
of Account
Account Holder P R E F I X F I R S T M I D D L E L A S T

Name of Bank Branch

Account Number Current Savings Banking Since Years

Financial Details
Particulars Applicant (`) Co-Applicant (`)
Saving in Bank Deposits
Other Immovable Properties

Current balance in PF/PPF

Life Insurance Policies/PLI

Shares and Securities

Is this the first residential property within your
you family?
family? Yes
Yes No
No Other Assets Car Two Wheeler

Other Facility Taken/Proposed

Particulars Applicant Co-Applicant
EMI Outstanding Bal. EMI Outstanding Bal.
Facility Amount Months Facility Amount Months
House
Car
Loan Against PF/Bank OD

Others
Others
(Specify)
Have you given gaurantee for any borrower of ICICI Bank Yes No

DECLARATION/S
1. The Applicant/s declare that all the particulars and information given in the application form
are true, correct, complete and upto date in all respects and the Applicant/s
have not with-held any information whatsoever. The Applicant/s confirm that the they have
no insolvency proceeding initiated against them nor have they ever been adjudicated
insolvent / bankrupt. The Applicant/s have read the application form and brochures and are
agreeable to all the terms / conditions of availing finance from ICICI Bank. The Applicant/s
authorise ICICI Bank / its Group Companies / its Agents to make references and enquiries
relevant to information in this application form which ICICI Bank / its Group Companies / its
Agents consider necessary. The Applicant/s undertake to inform ICICI Bank / Group
Companies / its Agents regarding the change in the residential addresses to provide any
further information that ICICI Bank / its Group Companies / its Agents may
require......................................................................................................................
2. The Applicant/s further declare and confirm that the credit facility/ies if any enjoyed by the
Applicant/s with other banks has been disclosed here in above..............................................
3. The Applicant/s declare that we have read the application form and brochure and are
agreeable to the terms / conditions of availing the credit facility/ies mentioned herein from
ICICI Bank.........................................................................................................................
4. The Applicant/s understand that certain particulars given by the Applicant/s are required for
by the operational guidelines governing banking companies..............................................
5. The Applicant/s hereby agree and authorize ICICI Bank / its Group Companies to exchange,
share or part with all the information, data or document in relation to the application including
but not limited to the credit repayment, history or any default, if any, committed by the
Applicant/s to credit bureaus, agencies, statutory bodies....................................................
6. Save and except to the extent as disclosed in this application, the Applicant/s (if a person
other than a subsidiary of ICICI Bank or a section 25 company or a government
company, or in case of facility/ies are not encompassed by the restrictions specified by the
Reserve Bank of India [ RBI ] from time to time) represents that: no director or a
relative/near relation (as specified by RBI) of a director of a banking company (including ICICI
Bank) or a relative near relation (as specified by the RBI) of a senior officer of ICICI
Bank (as specified by RBI) is a partner of the Applicant/s, a director, manager, employee of
the Applicant/s or of a subsidiary of the Applicant/s or a subsidiary or the holding
company of the Applicant/s, or a guarantor on behalf of / for / to the Applicant/s, or holds
substantial interest in the Applicant/s, or a subsidiary of the holding company of the
Applicant/s. Yes No .....................................................................................
7. The Applicant/s agree that ICICI Bank may provide the credit facility/ies mentioned herein
only if permitted and if approved in the manner specified or required by the Reserve
Bank of India from time to time......................................................................................
8. The Applicant/s agree and understand that ICICI Bank reserves the right to reject this
application without assigning any reason (unless required by applicable law), and
that ICICI Bank shall not be responsible / liable in any manner whatsoever to the
Applicant/s for such rejection or any delay in notifying the Applicant/s of such rejection
and any costs, losses, damages or expenses, or other consequences, caused by reason of
such rejection, or any delay in notifying the Applicant/s of such rejection, of this
application.........................................................................................................................
9. The Applicant/s acknowledges that ICICI Bank Limited / its Group Companies reserves the
right to retain the photographs and documents submitted with this application and will not
return the same to the applicant/s......................................................................................
10.The Applicant/s hereby declare and affirm that the Applicant/s have not made any
payments in cash. ........................................................................................................
11. The Applicant/s hereby declare that the information of GSTIN with respect to the number
and billing address is correct and Bank can update the same in its records. The Applicant/s
hereby declare that the information provided can be used by ICICI Bank for the purposes of
charging GST and reporting of transactions on theGSTN portal and for other related
aspects in relation to reporting as stated under GST Act and applicable rules in this regard.
12.The Applicant/s hereby understand that in case of non-provision/non-updation of mobile
number, they would not receive SMS alerts pertaining to the account and shall not hold
ICICI Bank liable for the same.

SPECIFIC DECLARATION

1. ICICI Bank Limited, its group companies, agents/representatives, would like to keep 2. The Applicant/s hereby authorizes ICICI Bank to exchange, share or part with all information/
our customers updated on various products and services related information and data provided herein including personal and business information with ICICI group companies/
special offer from ICICI Bank/group companies and other entities. Please help us to other institutions/ such other persons as may be necessary/ required for the purpose of,
serve you better by giving your consent to receive such information (Please tick, including but not limited to, marketing, cross selling of various products and services etc
appropriately); to me/us, use or process the aforesaid information/data by such person/s, or furnishing of
a Email Alerts the processed information/ data/ products thereof to other Banks/Institutions/other persons
Yes No
as may be necessary, and we shall not hold ICICI Bank liable in connection with the use of
b SMS Alerts Yes No such information or otherwise. Yes No

c Phone Call Yes No

Note: No payments should be done in cash. The cheque should be filled and signed by the
applicant/ co-applicant.
Signature of the Co-applicant