Loan Application Form

Please fill in all details in the form only in BLOCK LETTERS. All the fields in the application are mandatory and should be
neatly and completely filled.

Date: / / Application Form No:

Region: Referred By:
SM/RM Code:

To:
ICICI Securities Ltd
Shree Sawan Knowledge Park Fix your
Plot No.D-507, TTC Industrial Area,MIDC, Turbhe, Navi Mumbai 705 Recent
Dear Sir/Madam, Passport Size
I the undersigned,hereby apply for grant of an Partner code to me for marketing of various loan
products offered by ICICI Securities Ltd. as a Loan Partner and furnish the information given
Photograph
below: (To be filled up in CAPITAL LETTERS)

Name:
Father's Name/Husband's Name:

/ / Gender: Male Female Other

Name of the Firm Trade Name (If any):

Date of Birth:

PAN:
Office Address Residence Address
Flat No./Plot
No:
Society
Name:
Area/
Locality:
City Landmar State:
: k: PIN Flat No./Plot
: No:
Society
Email Name:
Area/
id: Locality:
City Landmar
State: : k: PIN
Phone: Phone :
Education Qualification: :
Occupation:
Products Dealing in:
Business Experience in years:
Are you related to any member of ICICI Group:(Yes/No):
If yes, please mention their Name and Relationship:

Bank Account Details:

ICICI Bank Account Other Bank Account

Bank Bank

Account No:
Branch: Account No:
NEFT: Branch:
NEFT:
MICR:
Nominee Details:

Name and Address of Nominee:

Age of Nominee:
Relationship with Applicant:

Name and Address of Guardian (in case nominee is minor):

Products Available as a Loan Partner:

Business Loan Two Wheeler Loan

Personal Loan Car Loan Jewellery Loan

Credit Cards LRD SME Loan

Travel Cards Remittances Forex Services

Loan against Share

GST DECLARATION
(For Loan Partners)
Application form:
Partner Code:

Name of the Loan Partner:

GST Registered:
No Yes (If ‘Yes’ fill below details )

PAN:
GSTN Number:
SAC / HSN Code:

I hereby declare that the details furnished above are true and correct and I undertake to inform you of any changes
therein, immediately. I hereby also declare anf confirm that my registered address updated with ICICI Securities Ltd. is
latest and to be considered for all GST related purposes. 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: ___________________
Place: ___________________
* If partner declares that he is not registered with GSTN, then he should inform GST Registration details in future
whenever he will obtain the same.

DOCUMENT CHECKLIST
# Documents to be attached along with this Form
1) PAN Card Copy
2) Cancelled Cheque, If Name not printed on cheque the provide the Bank statement.
3) Residence proof ( any one from the below)
a) Voter Id card b) Passport c) driving License d) Telephone/Electricity Bill e) Bank Statement/Bank Pass Book (Attested &
Stamped by Bank Official) f) Rent agreement g) Ration card h) BVL
Pan card copy not available. 3) Any other docs as per RCU guidelines

Applicant's Signature:_______________________________Date:_________________
TERMS AND CONDITONS FOR APPOINTMENT AS LOAN PARTNER FOR DISTRIBUTING PRODUCTS OF THE BANKS/ NBFC
The loan partner (hereinafter referred to as partner) shall be appointed as a referral agent to perform such services as
defined in the scope of services or as communicated from time to time by ICICI Securities Limited. The appointment as
Referral agent shall not be construed as employment with ICICI Securities Limited (hereinafter referred to as I-Sec). Such
agent shall not conduct himself in any manner, which could conflict with the interest of the Company.
The terms and conditions which shall govern the provisions of the referral and distribution arrangement / services are
mentioned below:-

SCOPE OF SERVICES
a) In the event that any person is desirous of availing loan products of the banks/ NBFCs, such partner shall refer such
person to I-Sec, in a form and manner as required by I-Sec.
b) I-Sec, in its capacity as distributor/ referral agent or in any other capacity, is also providing services / distributing
products of various banks and is duly authorized to appoint sub-distributor/ referral agent. The partner is desirous to
act as referral to I-Sec. Such partner shall act through such branches or offices in India as may be intimated to ICICI
Securities.
c) Partners are not authorised to solicit business directly from client representing as an agent/partners of the Company.
Scope of arrangement would be limited to the partners referring lead to the Company. Thereafter all interactions with
clients for necessary closure will be undertaken by employees of ICICI.
The partner is desirous to act as referral to i-Sec.
Such partner shall act through such branches or offices in India as may be intimated to perform services as agreed
thereto or such other services as may be mutually agreed between the parties from time to time and such partner
hereby accepts such appointment on the terms set out hereinafter.

OBLIGATIONS OF THE LOAN PARTNER

1) Such partner undertakes to provide details of all such referrals, in a form and manner as may be determined by I-Sec,
to the I-Sec within such periodicity (daily/ fortnightly/monthly/semi-annually/ annually) as may be required by the
Company.
2) Such partner acknowledges the discretionary right of the client to continue client relationship with I-Sec at his
discretion. Discontinuance of relationship, if any, between the partner and the I-Sec will not have any effect to the
contract entered into between I-Sec and the said client.
3) Such partner agrees to assist I-Sec in complying with provisions of Prevention of Money Laundering Act, 2002 or its
amendment thereof and such other rules, regulation etc. as may notified from time to time and as mutually agreed
between the parties.
4) The partner understands that he is solely responsible to ensure that in case of any application received from client,
the same is submitted to I-Sec in a timely manner. The partner shall be responsible for any loss arising to I-Sec/ client
due to delay in submitting the application shall be borne by partner. The partner agrees to hold I-Sec harmless against
any such loss.
5) The partner shall not make any misrepresentation to the client relating to the products or the banks / NBFC and shall
not make any false statement relating to the same.
6) The partner agrees not to make any statement, representation or claim nor give any warranties to any person in
respect of the business of I-Sec.
7) The partner ensures that all the queries of the client are resolved to the satisfaction of the client or he may forward
the queries to I-Sec.
8) The partner shall conduct himself with propriety and decorum at all times and in the manner which is not prejudicial
to the interest of I-Sec.
9) The partner shall not use nor display the name, logo, or mark of I-Sec in any manner, unless in the specified agreed
manner.
10) The partner agrees that the I-Sec shall at all times during the tenure of this arrangement, be entitled to monitor and
assess the performance of the partner.
11) The partner understands that the loan facility is subject to the fulfillment of eligibility criteria, terms and conditions
laid down by banks/ NBFCs etc.
12) The right of acceptance or rejection of any application shall rest with the bank / NBFC/ I-Sec.
13) The partner agrees to make good any losses that may be suffered by I-Sec which may arise due to any cost, actions,
claims, losses, damages, suits, prosecutions, including all consequential loss and legal fees due to any reason
attributable to the partner.
CONSIDERATION
a) I-Sec shall pay such fees/ commissions to the partner and subject to such conditions as may be mutually agreed
between I-Sec and partner.
b) The rates of referral fees/ commissions are subject to revision by I-Sec from time to time and partner shall be bound
by the said revisions.
c) In the event any discrepancies / excess payment, then partner shall reimburse I-Sec for all such amounts.
d) All the payment to be made by I-Sec under the terms of this arrangement shall be subject to the deductions of all
applicable tax.
e) Further, the Company may at its sole discretion decide not to pay fees/ commission to the partner with respect to any
particular clients.
f) "ICICI Securities reserves the right to add or remove products time to time without prior notice."
g) By signing this agreement you give your consent to ICICI Securities and its affiliates to call you even if your phone
number is registered on the DNC/DND list.

ASSIGNMENT / APPOINTMENT OF SUB-AGENT

The partner / agent shall itself perform its obligation under this arrangement and shall not assign, transfer or sub
delegate any of its rights and obligation under this arrangement except prior written permission of I-Sec.

NO WARRANTIES WITHOUT AUTHORITY

The partner shall not make any representation concerning any products of the banks/ NBFCs except those contained in
the printed information issued by such banks/ NBFCs.

CONFIDENTIALITY
a) All details, documents, data applications, software, systems, papers, statements, business / customer information and
Company’s practices and trade secrets (hereinafter referred to as ‘Confidential information’) which may be
communicated to the partner / or its employees shall be treated as absolutely confidential and the partner
 irrevocably agrees and undertakes that he and all its employees shall keep the same secret and confidential and not
disclose the same, in whole or in part to any person without the prior written permission of I-Sec shall use or allow to
be used any information than as may be necessary for the due performance of the obligation of the partner. The
partner hereby specifically agrees to make good any loss that may be suffered by I-Sec arising out of any breach of
this arrangement by such partner and / or its employees and immediately reimburse and pay to I-Sec on demand all
damages, loss, cost, expenses or any charges that Company may suffer, incur or pay in connection therewith.
b) The partner shall take all necessary action to protect the confidential information against misuse, loss, destruction,
deletion and / or alteration.
c) The partner shall not misuse or permit misuse directly or indirectly, nor commercially exploit the confidential
information for economic or other benefit.
d) The partner shall not retain any copies or record of any confidential information provided by I-Sec other than as may
be required for the performance of any obligation under this arrangement.
e) The partner shall notify I-Sec promptly of any unauthorized or improper use or disclosure of the confidential
information.
f) The partner shall return all the confidential information belonging to I-Sec which is in his custody, at the time of
termination of this arrangement.

INDEMNITY
The partner hereby indemnifies and shall always keep indemnified I-Sec against all cost, actions, claims, losses, damages,
suits, prosecutions, including all consequential, loss and legal fees which I-Sec may suffer/ incur on account of the failure
or default on the part of partner to the I-Sec in whole or any part of the terms and conditions.

TERMINATION
a) I-Sec shall be entitled to terminate the arrangement forthwith and at any time and without giving any notice or
payment in lieu of notice in the conditions, if any instance of moral turpitude, dishonesty, fraud, forgery, and
unbecoming conduct on the part of partner is identified or becomes known.
b) In the event of this arrangement being terminated as aforesaid, all of the obligations and undertaking of each party,
save and except any accrued and unpaid obligations of such party, shall terminate forthwith on such date or
termination, provided that in relation to such unfulfilled payment obligation of a party, the arrangement shall
continue till such payment obligation has been fulfilled to the satisfaction of the party entitled to such payment
thereof.
c) In case of termination of the arrangement by the Company, any fees/ commissions for the relevant previous month is
liable to be forfeited by I-Sec at its sole discretion.
d) The termination of this arrangement by either party for any reason whatsoever shall not in any manner affect the
status of any client already registered with I-Sec either before, or pursuant to, the execution of this arrangement.
e) If any of the directions and instructions as specified herein or may be, from time to time, issued by respective banks/
NBFC/ I-Sec are not complied by partner.

ADVISORS-DO’S AND DON’TS

Do’s
1) Maintain high standards of integrity, promptitude and fairness in the conduct of your activities and act with due skill,
care and diligence at all times.
2) Update your contact details in the records of I-Sec immediately whenever there is a change thereof.
3) Ensure that you are updated with the latest requirements pertaining to the products distributed by you. Obtain
necessary information from your relationship manager.
4) Provide true and adequate information to the applicants without any misleading or exaggerated claims.
5) Read all the information given in the application forms carefully and guide the applicant to complete the form and
ensure that the applicants interest is protected
6) Advise the client to read the entire application form for proper understanding.
7) Ensure that the applicant fills up the application form completely as per the format given.
8) Obtain all the necessary documents from the applicant as per directions mentioned on the application form.
9) Disclose full, latest and all material information to the applicant including about the charges applicable on the
services offered.
10) Resolve queries of applicant in a fair and expeditious manner. If you have any queries, please contact your Channel
Manager for guidance.

Don’ts
1) Do not solicit applications in fictitious/benami name or on an anonymous basis.
2) Do not accept copies of KYC documents that appear to be forged, or that are not clear.
3) Do not involves in malpractices to earn higher commission or faulty/unethical business practices.
4) Do not use unethical means to market or induce any applicant to avail the products.
5) Do not make false promises to the applicants.
6) Do not obtain unwanted extra signatures of the applicants on the form
7) Do not inward forms that are not complete in all respects or use unethical means to rectify rejections in the
application forms.
8) Maintain Highest confidentiality of client details. Do not disclose, share or discuss with any other person or make

improper use of details and documents/ report of any client. Any misconduct observed in this regard will be strictly

actioned upon. Name of Applicant:___________________________________

Signature of Applicant:__________________