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Kyc Page No 3 Latest

The document is a KYC application form for individuals, requiring personal and identification details such as name, address, and contact information. It includes sections for identity verification, proof of address, and tax residency status. The applicant must declare the accuracy of the information provided and consent to sharing their Aadhaar details for KYC purposes.

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12 views1 page

Kyc Page No 3 Latest

The document is a KYC application form for individuals, requiring personal and identification details such as name, address, and contact information. It includes sections for identity verification, proof of address, and tax residency status. The applicant must declare the accuracy of the information provided and consent to sharing their Aadhaar details for KYC purposes.

Uploaded by

gidok44675
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Know Your Client (KYC) Application Form – For Individuals

KYC Mode: Online KYC Normal EKYC OTP Offline E-kyc


New Change Request (Please fill this form in ENGLISH and in BLOCK LETTERS)
(Please tick the box on left margin of appropriate row where the CHANGE/CORRECTION is required and provide the details in the
corresponding row)
A. IDENTITY DETAILS
1. Name of the Applicant:*
2. Father’s/Spouse’s Name:*
3. Mother’s Name:*
4. Maiden Name:*
5. A. Gender:* Male Female Transgender B. Marital Status:* Single Married
C. Date of Birth:* 00 / 00 / 0000
6. Nationality* Indian Other (Please Specify)
Status* Resident Individual Non Resident
Foreign National (Passport Copy Mandatory)
7. A. PAN:* B. (UID)/Aadhaar, if any:
8. Proof of Identity Submitted PAN Card
B. ADDRESS DETAILS
1.Correspondence Address:*
Address Line 1 :
Address Line 2 :
Address Line 3 :
City/Town/Village: PIN Code: 0
State: Country:
2. Specify Proof of Address submitted for Residence/Correspondence Address:
3. Permanent Address:* if different from above or overseas address, (mandatory for Non-Resident Applicant)
Address Line 1 :
Address Line 2 :
Address Line 3 :
City/Town/Village: PIN Code: 0
State: Country:
4. Specify Proof of Address submitted for Permanent Address:*

5. Contact Details
a. Mobile Number:* b. EMAIL ID:*
c. Tel. (Office): d. Tel. (Residence):
6. Any other Information : ____________________
7. Are you a Tax Resident of any country other than India? Yes No
(if yes , please indicate all countries in which you are resident for tax purposes and the associated Tax ID Numbers below)
Country Tax Identification Number % Identification Type(TIN or Other , Please specify)

C. DECLARATION
I/We hereby declare that the KYC details furnished by me are true and correct to the best of my/our knowledge and belief and I/we under-take 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/We are aware that I/We
may be held liable for it. I/We hereby consent to receiving information from CVL KRA through SMS/Email on the above registered number/Email address. I am/We
are also aware that for Aadhaar OVD based KYC, my KYC request shall be validated against Aadhaar details. I/We hereby consent to sharing my/our masked
Aadhaar card with readable QR code or my Aadhaar XML/Digilocker XML file, along with passcode and as applicable, with KRA and other Intermediaries with
whom I have a business relationship for KYC purposes only.

Seal & Signature of Authorized Signatory


FOR OFFICE USE ONLY
FARHAN NAIK 4.
In Person Verification (IPV) Details: SENIOR EXECUTIVE
Name of the person who has done the IPV: E0118
Designation: SAMCO SECURITIES LIMITED
Employee ID: 20/04/2023
Name of the Organization :
Date of IPV :
Originals Verified and Self Attested Document Copies Received:
Attested True copies of documents received
Main Intermediary:
POS Code:1200000935
Date : 30/05/2023 Place

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