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(Individual Know Your Customer)

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Full Name

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District Municipality/V.D.C. Ward
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(Permanent Address) 6f]n÷ufFp 3/ g+= kmf]g g+==
Tole/Villege House No. Phone No.

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Mobile No. Email

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District Municipality/V.D.C. Ward
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(Recent Address) 6f]n÷ufpF 3/ g+= kmf]g g+==
Tole/Villege House No. Phone No.

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Date of Birth B.S. A.D. Nationality Religon

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Citizenship No. Issuing Office Issued Date

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Passport No.(If taken) Issuing Office Issued Date

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Type of ID ID No.
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Employee Identification
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Issuing Office Issuing Date

-;/sf/L, ;fj{hlgs ;+:yf tyf ;+ul7t ;+:yfsf g]kfnL sd{rf/Lsf] xsdf_ (In Case of employee of any Govt. Institutions/Office/Firm/Company)

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Remittance (Mention name of country) Return on Investment Salary Income Business Income
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Source of Income
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Inheritance Others (Please specify) PAN No.:

vftfjfnf u|fxssf] kl/jf/ ;b:o ;DaGwdf (Details of family member of account holder)

gftf÷Relationship gfd y/ Full Name

klt÷kTgL ÷Spouse

afa'÷Father

cfdf÷Mother

afh]÷Grandfather

5f]/f÷Son

5f]/L÷Daughter

a'xf/L÷Daughter in law (Son's wife)

;;'/f÷Father in law

vftfjfnf ;+nUg /x]sf] k]zf÷Jojzfo (Details of Account holder's occupation/bussiness)

;+:yfsf] gfd ;+:yfsf] 7]ufgf kb cg'dflgt jflif{s cfDbfgL÷kfl/>lds -g]=?=_

Name of Institution/Firm/Company Address of Institution Position/Designation Estimated Annual Income/Remuneration (NPR)

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Location Map of Customer:
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Customer's Signature

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 aflif{s sf/f]af/ x'g] cg'dflgt /sd Ps nfv;Dd kfFr nfv;Dd kfFr b]lv bz nfv;Dd bz nfveGbf dfly
Expected Annual Turnover Upto One Lakh Upto Five Lakh Five Lakh to Ten Lakh Above One Million

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Education SLC or Below Intermediate or +2 Bachelor Master or Above

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Are you Government Official or High Level Official? yes No If yes, please mention the post

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yes No If yes, please mention: Name of Party Post
Are you a Politician or a Relative of a Politician?

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yes No
Do you have any beneficiary?

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If yes, please provide your beneficiary's name and relation with you.

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Name: Relation:

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Do you have an account in Century Bank? yes No

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If yes please provide description below.

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A/c No.: Branch:

s] tkfO{n] ;]~r'/L a}+ssf] Debit Card ;]jf pkef]u ug'{ ePsf] 5 < 5 5}g
Have you used Debit Card Service of Century Bank? yes No

s] tkfO{ ljutdf s'g} ck/fwdf bl08t x'g' ePsf] 5 < 5 5}g

Did you ever convicted in any crime ? yes No

Foreign Account Tax Compliance Act (FATCA)

This form must be completed by any individual who wishes to open a banking account.

Name:

Country of residence:

Country of Birth:

Please check the box as appropriate of the following question:

1. Are You

A. U.S. Resident ? Yes No

B. U.S. Citizen? Yes No

C. Holding U.S. Permanent Resident Card (Green Card)? Yes No

FATCA Indicia
1. Is the residential address mentioned in account opening form a care of address?

Yes No

2. Please check the appropriate box if any statement below applies to you?

a. I Have
i. Granted a power of attorney to a person who has a U.S. address, or
ii. Authorised a person who has a U.S. address to operate the banking account (either physically or electronically)

I hereby confirm the information provided above is true, accurate and complete

Subject to applicable local laws, I hereby consent Century Commercial Bank Limited or any of its affiliates (Including branches) to share my information with domestic and overseas tax authorities where necessary
to establish my tax liability in any jurisdiction.

Where required by domestic or overseas regulators or tax authorities, I consent and agree that the Bank may withhold from my account(s) such amount as may be required to applicable laws, regulations and
directives.

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Customer's Signature:

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Date:

ccbl_kyc_1