CENTRAL KYC REGISTRY

Know Your Customer (KYC) Application Form for Individual

Ck001

Primary Applicant
Prefix First Name Middle Name Last Name
Name* (Same as ID proof)

Maiden Name (If any*)

Father Name*

Mother Name*

Passport Expiry Date D D M M Y Y Y Y Required if Passport provided as Identity/Address Proof

Driving License Expiry Date D D M M Y Y Y Y Required if Driving License provided as Identity/Address Proof

Occupation Type* Private Sector Public Sector Government Sector Business Professional
Self Employed Retired Housewife Student
DECLARATION
• I 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 or misleading or misrepresenting, I/We am/are aware that I/we may be held liable for it.
• My personal / KYC details may be shared with Central KYC Registry
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered
number/email address
Signature of
Date D D M M Y Y Y Y Place: ______________________________________ Primary Applicant

1st Joint Applicant

Prefix First Name Middle Name Last Name
Name* (Same as ID proof)

Maiden Name (If any*)

Father Name*

Mother Name*

Passport Expiry Date D D M M Y Y Y Y Required if Passport provided as Identity/Address Proof

Driving License Expiry Date D D M M Y Y Y Y Required if Driving License provided as Identity/Address Proof

Occupation Type* Private Sector Public Sector Government Sector Business Professional
Self Employed Retired Housewife Student
DECLARATION
• I 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 or misleading or misrepresenting, I/We am/are aware that I/we may be held liable for it.
• My personal / KYC details may be shared with Central KYC Registry
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered
number/email address
Signature of
Date D D M M Y Y Y Y Place: ______________________________________ 1st Joint Applicant

2nd Joint Applicant

Prefix First Name Middle Name Last Name
Name* (Same as ID proof)

Maiden Name (If any*)

Father Name*

Mother Name*

Passport Expiry Date D D M M Y Y Y Y Required if Passport provided as Identity/Address Proof

Driving License Expiry Date D D M M Y Y Y Y Required if Driving License provided as Identity/Address Proof

Occupation Type* Private Sector Public Sector Government Sector Business Professional
Self Employed Retired Housewife Student
DECLARATION
• I 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 or misleading or misrepresenting, I/We am/are aware that I/we may be held liable for it.
• My personal / KYC details may be shared with Central KYC Registry
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered
number/email address
Signature of
Date D D M M Y Y Y Y Place: ______________________________________ 2nd Joint Applicant
 3rd Joint Applicant
Prefix First Name Middle Name Last Name
Name* (Same as ID proof)

Maiden Name (If any*)

Father Name*

Mother Name*

Passport Expiry Date D D M M Y Y Y Y Required if Passport provided as Identity/Address Proof

Driving License Expiry Date D D M M Y Y Y Y Required if Driving License provided as Identity/Address Proof

Occupation Type* Private Sector Public Sector Government Sector Business Professional
Self Employed Retired Housewife Student
DECLARATION
• I 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 or misleading or misrepresenting, I/We am/are aware that I/we may be held liable for it.
• My personal / KYC details may be shared with Central KYC Registry
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered
number/email address
Signature of
Date D D M M Y Y Y Y Place: ______________________________________ 3rd Joint Applicant

V.01/CKYC Form/10-02-2016

FOR OFFICE USE ONLY

Documents Received Self-Certified True Copies Notary
IN PERSON VERIFICATION CARRIED OUT BY
Identity Verification Done Date D D M M Y Y Y Y
Emp. Name :______________________________________________________

Emp. Code :______________________________________________________

Emp. Designation :_________________________________________________

Emp. Branch:______________________________________________________ Employee Signature