BT creo Ce astra CUSTOMER MASTER FORM/ KNOW YOUR CUSTOMER (KYC) CKYCR FORM FOR INDIVIDUALS MUST BE TAKEN FROM ALL APPLICANTS SEPARATELY IN JOINT ACCOUNTS INSTRUCTIONS FOR FILLING THE FORM: A) Folds marked with*™are mandatory felds. ©) Incase of joint applicants or related party, each applicant B) In case of ‘Small Account type' only personal details in to fla separate form Section -1, 5 and, photograph, signature and | D) All demographic details should be captured as per self-certification of documents is required ‘Aachaar card ‘APPLICANT TYPE: Bnew Oexstine I Edoting le ticked: CUSTOMER ID NO, prfornatice to me, |[glvemy consent that found otherafse, bank reserves the right to consoldate the customer kis as tmay deco, without any ‘CUSTOMER ID (For NEW) For Office Use Only (To be filed by Bank/Branch) KYC NUMBER (As per CERSAI) (KYG NUMBER is, mandatory for KYG update request) Concerned detail be fited (D4. PERSONAL DETAILS (Pioase rofer instruction Hat tho ond) Clr Mrs LIM a2 Asahar) pate 207 Father Name* Mother Name ardn name * Relationship of Guardian wh Minar Date of Bth *(DDNMYYYY Genders: C] Mate Creme, C1] 16-transgender| Marta etatus® Cimaries, []Unmamies [Jeter (ph. Speci H Nationa” Clinaan [Joters (150.2186 County Code) CL] \atnalctmre nan cro corey, pace menton aie coureos spare by a cra) note [Realdental Statua* T]Residentinaivcuar — [_]Non Resisentnaian[_] Foreign Navonel Person ot naan ohn ‘Occupation Type™ 7 SALARIED Eicenat Tooorence CJRaiway _C]Steie Govt_[JPrivate Sector LJomers © BUSINESS T_Manvfactoing [J Trader [-] Agneutore [_] Others Piease speciy B_ OTHERS [EJ Reed EJ Student [Housewife [-] _W Not Gatogoized PL Specty ‘Annual income (Rs) | __=00000 | 60.001 t07Lakn | 1105 Lakh Sto 15 Laie > 15 Lake ‘Ranual Turnover/ Receipt from business (in case of Business) (Re Tn Lakh Category" [L_Genersi_ 086 Ose C1 tC) minority Customer Type" [Mor Ese cron Penserar TNT cers CT gap sor [1 miernte ]Pardenashin CJ ane] Pylety Henleapped []_ other Soest. ‘OPTIONAL INFORMATION : |W to share folowing information (VES 7 NO) tyes Flin the folowh Information 2: Education Qualfeation Tlundor Graduate [ ]Graduate Lost graduate thers Retgon rin mstin isin Llcwistion Tooter PNB 1228(A)/2017 1of4(J 2. Ts eras PAN® (I PAN not avalabo, fil forn 60) [C]_3._AADHAAR AND E-KYC DETAILS* AADHAAR NUMBER EKYC DONE Ores [ne E-KYC Rotorence No, (foe fled by Branch Of) [AADHAAR ENROLLMENT NO |ntwhen Aadhaar Number not avaiable | ‘If Aadhaar Enrolment Numbers glven & PAN fs nt avalible then also prove KYC documents as per ham 4 below: (L]_4._PROOF OF IDENTITY ANDIOR PROOF OF ADDRESS (Please refer instruction ‘C' in Annexure EKYC R-1, atthe end) Tiox | TYPE (Name of POD) Document No. Date of issue Date of expiry Passport No. Manéatory For NRL f-Deving Ueense JF -NREGA ob cara eter ued by National Population Rewer ar other documents as identified by dentiieation No ental Govt, containing details of name & adres, fe others {sentncaton Na, [Any document ntited by Central Govt) Refer Annenure CKYER, POI NOBS (I 5. ADDRESSES ‘A._ADDRESS AS PER ADHAAR": Whether itis: [PERMANENT [CORRESPONDENCE [sora [inet [nea line @ CiyTownNitage [staoruT [stae/UT Code Pin Post Code" 180 3168 county code B._CORRESPONDENCE/LOCAL ADDRESS*(Fill only if different from Aadhar address) Line 4 (cine lune @ CiyTewnNitage [staerUT [stae/UT Code Post Code™ 180 3166 county code G._ OFFICE/BUSINESS ADDRESS (if available) lune linea {Line 3 CiyiTownVilage [stareruT [stae/UT Code PinPost Code™ 180 3166 county code D._ OVERSEAS ADDRESS (Applicable Mandatorly for NRUPIO etc) [Overseas Office Address( Landmark is compulsory) (Overseas Resldental Address lctyrrownnitage lcryrtownvitage Jcountry Name: Code. loounty Name: Code. IPhone No. Fax No, IPhone No. Fax No lemait Address: femal Adcress: 2of4(D6. CONTACT DETAILS (All communications will be sent on registered Mobile No/Email ID) Wobie Number Tel, Number tobe repstered) {wie STO} Email (oberenisered) [1] 7. FATCAICRS SELF CERTIFICATION / DECLARATION FOR INDIVIDUALS" ‘Are you a tax resident of any country other than India? No [_] Yes[] _Fyes, please fil the detalis on PNB 1227 6/2017 (I 8. DECLARATIONS* 8.1. [declare that | do not enjoy any credit facilities with your/other bank's branches [) ‘OR 8.2 I declare that | have following deposit accounts andlor credit facilities with yourfother bank's branches: Limit (in case of erent, Bank Branch ‘Type of AccountFacilty Account No. "Saige [1 9. DETAILS OF RELATED PERSON (please rofor Instructions ‘E’ in Annexure - EKYC-R4 atthe end ) (Separate customer master form to be ebtained for each related person) [Addition of Related Person Lideletion of Related Person No. of Related persons [_] Related Person Type __[_] Guardian of Minor [Clauthorized Representative /Signatory CUSTOMER CUSTOMER 1D) CUSTOMER 1 (CUSTOMER 1 (1) 10. APPLICANT DECLARATION™ hereby declare that the details furnished above in this form are true and correct to the best of my/our knowledge and belief and | undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue of misleading or misrepresenting, | am aware that | may be held liable for it Lagree to be bound by the terms & conditions, Instruction etc as outlined in the Annexure CKYCR-| and CKYCR- II and by the rules of FATCAICRS, Punjab National Bank and the RBI and any subsequent amendment(s). My personal / KYC including Aadhaar details may be shared with Central KYC Registry hereby give my consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address and to use my Aadhaar data for customer ID creation and for enabling Aadhaar Enabled Payment System & /or Direct Benefit Transfer facility > Date: Place: ‘Signature/Thumb Impression of Applicant 30f4