Prefix First Name Middle Name Last Name

BDAPD6240F
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual
Important Instructions:
A) Fields marked with ‘*’ are mandatory fields. E) List of State / U.T code as per Indian Motor Vehicle Act, 1988 is available at the end.
B) Please fill the form in English and in BLOCK letters. F) List of two character ISO 3166 country codes is available at the end.
C) Please fill the date in DD-MM-YYYY format. G) KYC number of applicant is mandatory for update application.
D) Please read section wise detailed guidelines / instructions H) For particular section update, please tick ( ) in the box available before the
at the end. section number and strike off the sections not required to be updated.
For office use only Application Type* New Update

(To be lled by nancial institution) KYC Number (Mandatory for KYC update request)
Account Type* Normal Simplified (for low risk customers) Small
1. PERSONAL DETAILS (Please refer instruction A at the end)
Prefix First Name Middle Name Last Name
Name* (Same as ID proof)
Miss NIRUPAMA DASH
Maiden Name (If any*)
Father / Spouse Name* MR SUBHAM DASH
Mother Name*
Date of Birth* D D
26-11-1969 M M Y Y Y Y
PHOTO
Gender* M- Male F- Female T-Transgender
Marital Status* Married Unmarried Others
Citizenship* IN- Indian Others (ISO 3166 Country Code )
Residential Status* Resident Individual Non Resident Indian

Foreign National Person of Indian Origin
Occupation Type* S-Service ( Private Sector Public Sector Government Sector )

O-Others ( Professional Self Employed Retired Housewife Student)
B-Business
X- Not Categorised
2. TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Please refer instruction B at the end)
ADDITIONAL DETAILS REQUIRED* (Mandatory only if section 2 is ticked)

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*
3. PROOF OF IDENTITY (PoI)* (Please refer instruction C at the end)

(Certi ed copy of any one of the following Proof of Identity[PoI] 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 BDAPD6240F
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
4. PROOF OF ADDRESS (PoA)*

4.1 CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS (Please see instruction D at the end)
(Certi ed copy of any one of the following Proof of Address [PoA] needs to be submitted)
Address Type* Residential / Business Residential Business Registered Office Unspecified

Proof of Address* Passport Driving Licence UID (Aadhaar)
Voter Identity Card NREGA Job Card Others please specify
Simplified Measures Account - Document Type code
Address
Line 1* PLOT NO-949/P, LANE-3 MAHAVEER
Line 2 NAGAR BHUBANESWAR Bhubaneswar
Line 3 Khorda Bhubaneswar(M.C) Budhes City / Town / Village* KHORDA
District* Khorda Pin / Post Code* 751006 State / U.T Code* OR ISO 3166 Country Code* IN
4.2 CORRESPONDENCE / LOCAL ADDRESS DETAILS * (Please see instruction E at the end)
Same as Current / Permanent / Overseas Address details (In case of multiple correspondence / local addresses, please fill ‘Annexure A1’)
Line 1*
Line 2
Line 3 City / Town / Village*
District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code*
4.3 ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked)
Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details
Line 1*
Line 2
Line 3 City / Town / Village*
State* ZIP / Post Code* ISO 3166 Country Code*
5. CONTACT DETAILS (All communications will be sent on provided Mobile no. / Email-ID) (Please refer instruction F at the end)
Tel. (Off) Tel. (Res) Mobile 9437409402

FAX Email ID [email protected]
6. DETAILS OF RELATED PERSON (In case of additional related persons, please fill ‘Annexure B1’ ) (please refer instruction G at the end)
Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available*)
Related Person Type* Guardian of Minor Assignee Authorized Representative
Prefix First Name Middle Name Last Name
Name*
(If KYC number and name are provided, below details of section 6 are optional)
PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end)
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
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
7. REMARKS (If any)
8. APPLICANT DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I under t a k e 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 aware that I may be held liable for it.
I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address.
[Signature / Thumb Impression]

Date : D D M M
17-07-2019 Y Y Y Y Place : KHORDA
9. ATTESTATION / FOR OFFICE USE ONLY
Documents Received Certified Copies
KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS
Date D D
17-07-2019M M Y Y Y Y Name NJ INDIA INVEST PVT LTD
Emp. Name SHACHI M. DESAI Code IN0104
Emp. Code S0813
Emp. Designation Executive Emp. Branch HO
[Signature / Thumb Impression]

Verified through Income Tax records
name="NIRUPAMA DASH"
dob="26-11-1969"
country="India"
dist="Khorda"
house="PLOT NO-949/P, LANE-3"
loc="BHUBANESWAR"
pc="751006"
po="Budheswari Colony"
state="Odisha"
street="MAHAVEER NAGAR"
subdist="Bhubaneswar"
vtc="Bhubaneswar(M.C)"
gender="F"
Photo
Created by NJ India Invest on 17/07/2019/17:57:54 from the Offline E-KYC XML submitted by investor
BDAPD6240F

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BDAPD6240F

For ofﬁce use only Application Type* New Update

Residential Status* Resident Individual Non Resident Indian

Occupation Type* S-Service ( Private Sector Public Sector Government Sector )

ADDITIONAL DETAILS REQUIRED* (Mandatory only if section 2 is ticked)

3. PROOF OF IDENTITY (PoI)* (Please refer instruction C at the end)

A- Passport Number Passport Expiry Date D D M M Y Y Y Y

4. PROOF OF ADDRESS (PoA)*

Address Type* Residential / Business Residential Business Registered Ofﬁce Unspeciﬁed

Tel. (Off) Tel. (Res) Mobile 9437409402

A- Passport Number Passport Expiry Date D D M M Y Y Y Y

7. REMARKS (If any)

[Signature / Thumb Impression]

9. ATTESTATION / FOR OFFICE USE ONLY

Documents Received Certified Copies

KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

Emp. Name SHACHI M. DESAI Code IN0104

Emp. Code S0813

Emp. Designation Executive Emp. Branch HO

[Signature / Thumb Impression]

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