TICK YOUR CHOICE OF ICICI BANK CREDIT CARD* (Tick just one)

ICICI Bank Emeralde Credit Card ICICI Bank Credit Card ICICI Bank Credit Card
Dual card (American Express and Mastercard) Dual card (American Express and Mastercard)

ICICI Bank Credit Card MakeMyTrip ICICI Bank MakeMyTrip ICICI Bank Platinum
Signature Credit Card Credit Card
Visa Visa
Manchester United Signature Credit Card
by ICICI Bank Manchester United Platinum Credit Card ICICI Bank Expression Credit Card
by ICICI Bank Visa Image Code:
Visa
InterMiles ICICI Bank Credit Card
InterMiles ICICI Bank Credit Card InterMiles ICICI Bank Credit Card
Dual Card
(American Express and Visa) Dual Card Dual Card
(American Express and Visa) (American Express and Visa)
Mine Credit Card by ICICI Bank
ICICI Bank HPCL Super Saver Credit Card ICICI Bank HPCL Coral Credit Card

ICICI Bank Platinum Chip Credit Card

ABOUT YOURSELF
All fields marked with* are mandatory.
Prefix First Name Middle Name Last Name

Name
(Same as ID proof)
Mr Vijay Bhatt
Maiden Name (if any)
Name to be printed on Credit Card* Vijay Bhatt
(Maximum 19 characters, including spaces)

Date of Birth* 19/09/1973

Father Name*

Mother Name* Sharda

Gender* ● M- Male F- Female Other Marital Status* ● Married Unmarried Other

Religion* Hindu Muslim Sikh Zorastrian Christian Buddhist Jain Others

(Mandatory fields)

Person with Disability Yes No

Category* General Scheduled Caste (SC) Scheduled Tribes Most Backward Others Backward
(Mandatory fields) (ST) (MBC) (OBC)

Residential Status* Indian NRI/Foreign National

Nationality (if other than Indian)

PAN* AESPB5466P

PROOF OF IDENTITY (PoI) & PROOF OF ADDRESS (PoA)

Proof of Address* Passport Driving Licence Voter ID Card NREGA Job Card National Population Aadhaar
E-KYC Authentication Offline verification of Aadhaar Proof of possession of Aadhar

Current Residential Address*

F71, Income Tax Colony, , Sector 21/22, CBD Belapur

Landmark City/District NAVI MUMBAI State/U.T code* MAHARASHTRA

Pin* 400703 Country ISO 3166 Country Code* Tel. (Resi.) Mobile (In India)
9930975364
Permanent Residential Address*
F71, Income Tax Colony, , Sector 21/22, CBD Belapur

Landmark City/District NAVI MUMBAI State/U.T code* MAHARASHTRA

Pin* 400703 Country ISO 3166 Country Code* Tel. (Resi.) Mobile (In India)

E-mail ID (Personal)* [email protected]

Type of Residence Bungalow Row House Flat Others (Please Specify) Year(s) at current address <2016
Residence Status* Owned Rented With parents Provided by Company With Relatives/Friends Others (Please Specify)

Family/Relative Reference 1 Name

Address

City* Pin*

STD code Tel.: Mobile

Relationship with applicant

 ABOUT YOUR WORK

Academic Qualification* Graduate / Diploma Holder Professional

Salaried Self-Employed Retired House wife Others Please specify

TOPSOURCE INFOTECH SOLUTIONS PVT LTD

Employer Details Public Ltd. Public Sector Multinational Others (Please specify)

Retailing Agriculture Real Estate Others (Please specify)

Consultant Others (Please specify)

OTHER
Employee ID (mandatory if salaried) No. of year(s) in current job* Total experience (No. of years)*

Net Annual Income* Gross Annual Income*

F71, Income Tax Colony,

Office Address*

Sector 21/22, CBD Belapur Landmark City/District NAVI MUMBAI

Pin* 400614 State/U.T code* MAHARASHTRA Country ISO 3166 Country Code* IN
STD code* 020 Tel.* 67637127 Ext* Mobile (In India)

Office E-mail ID* (Mandatory if salaried) [email protected]

SUPPLEMENTARY CREDIT CARD APPLICATION (Liability of the Supplementary Credit Card will be on the Primary Cardholder)

Please complete this section to apply for Supplementary Card. Supplementary Card can be issued to family members (over 18 years of age) of the Primary Cardholder

Relationship

Prefix First Name Middle Name Last Name

Name
Please sign across
Please send colour Photograph(s) only. This would be
Date of Birth* Gender* Male Female Others retained by us for our records. Please do not use pins, tapes
or staples to affix your photograph.

Name as desired on Card*

(Maximum 19 characters, including spaces)

Current Residential Address*

Landmark City/District State/U.T code*

Pin* Country ISO 3166 Country Code* Tel. (Resi.) Mobile (In India)

Father's Name

Mother's Name

Spouse Name

Maiden Name (if any)

PAN* KYC No

Proof of Address Property or Municipal tax re ceipt Pension or family pension payment orders (PPOs)

Utility bill which is not more than two months old

Electricity Bill Identity Card Water Bill

Permanent government employees Photo ID Card

Revised -Gas Connection card not more than 2 months old

Original Letter from Govt. bodies certifying residential address

Quarters allotment letter issued by Govt.

Registered License agreements along with recent utility bills not older than two months
in name of landlord

Piped Gas Bill Telephone Bill Post-Paid Mobile Phone

Rental Agreement & latest utility bills

Passport Number Voter ID Card Driving Licence NREGA Job Card National Population
Register Letter
Proof of Possession of Aadhaar E-KYC Authentication

Offline verification of Aadhaar

Bank Account or Post Office Savings Bank Account statement

Please provide separate documents for proof of identity and proof of residential address. Only a valid passport will be accepted in both cases. At any given
time, a maximum of 3 supplementary cards will be issued to a primary Cardholder including any supplementary cards issued against any other ICICI Bank
Primary Credit Card. **As per the provisions of Reserve Bank of India Master Circular (RBI/2009-10/73; DBOD, AML, BC, No. 2/14, 01, 001/ 2009-10) on Know
Your Customer (KYC) norms dated July 01, 2009, it is mandatory for all banks to update the customer identification documents (including photographs). We
confirm that the information given above is true and correct. We understand that the Primary Cardholder will be liable for all the charges incurred with the
Primary Card and the Supplementary Card. We jointly and severally agree to be bound by the Rules and Regulations of use of the Credit Card, copy of which
we have received and understood. In particular, we confirm the usage in strict accordance with the Exchange Control Regulations of the Reserve Bank of India.
We understand that in the event of failure to do so, we are liable for action under the Foreign Exchange Regulation Act, 1973 and may be debarred from holding
the ICICI Bank Credit Card, either at the instance of ICICI Bank or the RBI. We authorise ICICI Bank to verify information in this application and to receive and
exchange information about us with other banks, agencies, companies for marketing and administrative purposes or for prevention of frauds, etc.

SUBSCRIPTION FOR CREDIT CARD VALUE ADDED SERVICES

Preferred mailing address* Residence ● Office (Please select only one)

I want to subscribe for* Statement by e-mail ● Mobile Alerts

Mobile No. 9930975364 Alternate No.

E-mail ID [email protected]
Alternate E-mail ID [email protected]
I understand that under the alert facility, ICICI Bank will enable me to receive customer alert messages with respect to events /transactions relating to my Credit Card or
informational/promotional mail that will be useful to me over my mobile phone or through e-mail. I agree to receive communication on my alternate e-mail ID in case
the alert messages with respect to any event/ transaction are not delivered to my preferred e-mail ID. (subject to information provided in the Application Form). I agree
to abide by the Terms and Conditions of ICICI Bank in this regard.

Auto Debit Facility I want to subscribe I don’t want to subscribe

I, do hereby unconditionally and irrevocably authorise ICICI Bank Ltd. to raise the debit of my regular Credit Card payments against my Savings/ Current Account number

maintained with ICICI Bank Ltd. Branch, with an amount equivalent to the
Minimum Amount Due Total Amount Due (please tick one of the boxes) as indicated in the Monthly Statement of charges on the due date.

Note: Auto Debit Facility is only available to Savings/Current Account holders of ICICI Bank Ltd. with Operating Instructions Single/Either or Survivor/Anyone or Survivor.
If the option of debiting the Minimum Amount Due or Total Amount Due is not clearly indicated in this Auto Debit application, ICICI Bank will activate the option of
Minimum Amount Due by default.
 OTHER INFORMATION
I am interested to know more about the service(s)/products(s) selected below and hereby provide the consent to ICICI Bank and/or any third party/parties who
is/are offering the below products to contact me for the same. I understand that this service(s)/product(s) is an offer from the third party/parties mentioned
below and that the particulars contained in this form shall be shared with any third party pursuant to ICICI Bank arrangement with the third party for offering
the said service(s)/product(s), as may be required or as ICICI Bank may deem fit.
Please tick from the below mentioned service(s)/product(s):

Card Protection Plan (CPP) offered by CPP Wallet Assist service offered by
Assistance Services Pvt. Ltd. One Assist Consumer Solutions Pvt. Ltd.

We have now digitised our Welcome Kits as part of the GoGreen initiative, an endeavour to reduce use of paper and make our contribution to this noble cause. If
you have applied for any of these products, your Credit Card welcome pack shall carry the welcome letter and the card plastic only: ICICI Bank Sapphiro, ICICI
Bank Rubyx, ICICI Bank Coral, ICICI Bank HPCL Coral, ICICI Bank Platinum Chip Credit Cards, Mine Credit Card by ICICI Bank, ICICI Bank HPCL Super
Saver Credit Card by ICICI Bank, Manchester United Credit Cards by ICICI Bank and MakeMyTrip ICICI Bank Credit Cards.
The detailed membership guide, Terms & Conditions and Most Important Terms & Conditions (MITC) are available online in a PDF format. To download, please visit
www.icicibank.com/cc-ewelcomekits.
The physical copy of the membership guide, Terms and Conditions and MITC shall be made available by ICICI Bank upon request made by calling our Customer
Care.

Cross-sell Ref. No.: CRM ID:

Lead Generator EMP ID Lead Fulfiller EMP ID

Application Ref. No. 5201901546644 Logo 366

DMA Code: Promo Code:
HET Channel Code: Branch SOL ID: Company Code:

IP and Coordinates Name as per NSDL (PAN)

I am an existing InterMiles member Yes No Membership number

InterMiles Membership Tier Base Red Silver Gold Platinum

Application Type* ● New Update KYC Number

Account Type* Normal Minor Aadhar OTP based E-KYC (in non-face to face mode)

DOCUMENT UPLOAD MATRIX

Photograph

OVD (any one of the documents) Passport Driving License Voter ID Card NREGA Job Card

National Population Proof of Possession E-KYC Authentication Offline verification

Register Letter of Aadhaar of Aadhaar

Deemed OVD (any one of the document) Property or Municipal tax re ceipt Pension or family pension payment orders (PPOs)

Utility bill which is not more tha n two months old

Electricity Bill Identity Card

Water Bill

Permanent government employees Photo ID Card

Revised -Gas Connection card not more than 2 months old

Original Letter from Govt. bodies certifying residential address

Quarters allotment letter issued by Govt.

Registered License agreements along with recent utility bills not older than two months
in name of landlord
Piped Gas Bill Telephone Bill Post-Paid Mobile Phone

Bank account or Post office savings bank account statment

Customer Consent One Pager Rental Agreement & latest utility bills
Passport Number Voter ID Card Driving Licence NREGA Job Card National Population
Register Letter
Proof of Possession of Aadhaar E-KYC Authentication

Offline verification of Aadhaar

 I/We declare that all the particulars and information given in the application form are  DECLARATION FOR INFORMATION SHARING I/We have no objection to ICICI Bank
true, correct, complete and up to date in all respects and I/we have not withheld any Limited, its group companies, agents/representatives to provide me/us information on
information. I/We confirm that I/we have had no insolvency initiated against me/us nor various products, offers and services provided by ICICI Bank Limited/its group
have I/we ever been adjudicated insolvent. I/We have read the application form and companies through any mode (including without limitation through telephone
brochures and am/are aware of all the terms/conditions of availing finance from ICICI calls/SMSs/e-mails) and authorise ICICI Bank Limited, its group companies,
Bank Limited. I/We authorise ICICI Bank Limited to make references and enquiries agents/representatives for the above purpose.
related to information in this application which, ICICI Bank Limited considers necessary.
I/We undertake to inform ICICI Bank Limited regarding change in my/our
Yes ● No (Please tick Yes or No, as acceptable)
residence/employment and to provide any further information that ICICI Bank Limited  I authorize ICICI Bank Limited to share my information with any parent, subsidiary,
may require. affiliates or associate of ICICI Bank Limited or any third party on-boarded by/ associated
with ICICI Bank Limited, as may be required or as ICICI Bank Limited may deem fit for the
 I/We understand that certain particulars given by me/us are required by the operational purpose of marketing and offering various products and services and I shall not hold ICICI
guidelines governing banking companies. Bank responsible/liable for sharing of such information.
 I/We declare that I/we have read the application form and brochure and am/are Yes ● No (Please tick Yes or No, as acceptable)
agreeable to the terms/conditions of availing the Credit Card from ICICI Bank Limited.
 Internationally valid Card and all other Cards cannot be used on Internet or otherwise for
 I/We further agree to the terms governing the issuance of a Supplementary Card as
the purchase of prohibited items like lottery tickets, banned or proscribed magazines,
specified in the Terms and Conditions governing the Credit Card.
participation in sweepstakes, payment for callback services, remittance in any form
 I/We declare and undertake that the Credit Cards issued to me/us, if used overseas, shall towards overseas forex trading, margin calls to overseas exchanges/overseas
be utilised strictly in accordance with the relevant exchange control regulations issued counterparty, trading in foreign exchange in domestic/overseas markets including
and as amended by the Reserve Bank of India (RBI) from time to time. In the event I/we binary option trading with commodities, stocks, indices, virtual currencies, bitcoin index
exceed my/our entitlements as per the exchange control guidelines of RBI, I/we and forex etc. ICICI Bank does not deal in virtual currencies or provide services to any
undertake to bring the same immediately to the notice of ICICI Bank Limited in writing. person dealing in virtual currencies in any manner, such services including maintaining
Further, I/we also agree and understand that if I/we am/are required to get my/our accounts, registering, trading, settling, clearing, giving loans against virtual tokens,
passport endorsed for any charges incurred by me/us as stipulated by RBI, the onus of accepting them as collateral, opening accounts of exchanges dealing with them and
getting my/our passport endorsed shall lie entirely on me/us. In the event of any failure transfer / receipt of money in accounts relating to purchase/ sale of virtual currencies.
to comply with the prevailing exchange control guidelines issued by RBI to me/us, I/we
 I/We declare that, in the event of change in address due to relocation or any other
shall be liable for any action under the Foreign Exchange Management Act, 1999, as
reason, I would intimate the new address to the bank within 2 weeks of such a change.
amended and be debarred from the Credit Card facility either at ICICI Bank Limited
instance or by RBI.  I hereby give consent to ICICI Bank for linking my ICICI Bank Credit Card with my
existing ICICI Bank savings/current account, if any. I understand that this would enable
 In the event of a Credit Card programme closure or at the time of renewal of Credit Card,
me to access my ICICI Bank Credit Card account using the existing user ID provided to
ICICI Bank Limited at its sole discretion reserves the right to provide a card type that is
me under my ICICI Bank savings/current account, if any, through internet banking and
different from the existing card type held by the Cardholder. The credit limits and cash
iMobile facility. I provide consent to and authorize ICICI Bank to use the KYC details
limits on any Credit Card at any point in time are as per sole discretion of ICICI Bank
provided by me including but not limited to my Aadhaar card number for the aforesaid
Limited.
purpose. I further understand that I may delink my ICICI Bank savings/current account
 The card application shall continue to be valid for any replacement card provided at the from my ICICI Bank Credit Card by calling ICICI Bank Customer Care number available at
time of closure/renewal. www.icicibank.com.
 ICICI Bank Limited reserves the right to provide the applicant with a card type based on  I confirm and authorise to a) Use my Aadhaar details to authenticate me from UIDAI b)
information available with ICICI Bank Limited assessment of the applicant’s credit rating. Unique Identification Authority of India (UIDAI) to release my demographic details to
 I/We authorise ICICI Bank to exchange, share or part with all the information relating to ICICI Bank through biometric authentication which ICICI Bank may use for KYC
me/us and repayment history to credit bureaus, agencies, statutory bodies, market verification (identity/ address proof) for the purpose of Credit Card.
research agencies for conducting research as may be required and shall not hold ICICI  I/We declare Except to the extent disclosed to ICICI Bank, no director or a relative/near
Bank (or market research agencies) liable for use/sharing of this information. relation (as specified by RBI) of a director of a banking company (including ICICI Bank)
 I confirm that I am the sole account holder or I have the required mandate in case of joint or a relative/near relation (as specified by RBI) of a senior officer of ICICI Bank (as
accounts to singly operate accounts. specified by RBI) is: the applicant(s), or a partner of our concern, or a trustee, member,
director, manager, employee of our concern, or of our subsidiary, or our holding
 I/We understand that any change(s) in the Terms and Conditions will be communicated company, or a guarantor on my/our behalf, or holds substantial interest in our concern
to me/us and will also be available to me/us on request. or my/our subsidiary or holding company.
 InterMiles Membership: I/We authorize ICICI Bank to exchange, share or part with all the  Manchester United: I hereby consent to ICICI Bank Ltd. Sharing my Name, Contact
information relating to me/us as contained in this application form and/or the details of Details, Address, Year of Birth, Date of First Purchase and Date of Last Purchase with
the InterMiles ICICI Bank Credit Card, if any to be issued to me with the InterMiles Manchester United Football Club Limited and their affiliates for the purpose of
Programme Partner and/or any other third party pursuant to ICICI Bank arrangement marketing, curated offers etc. Yes No
with InterMiles/JetPrivilege and/or any other third party in relation to the InterMiles ICICI
Bank Credit Card, as may be required or as ICICI Bank may deem fit and I/We shall not Manchester United want you to be first to know about New Signings, Competitions,
hold ICICI Bank liable for use/sharing of this information. Note: If you are not an Club News, Ticket, Availability, and occasional offers from official sponsors and
InterMiles Member, you will be automatically enrolled. Also, if we do not receive your partners. To stay updated select Yes : Yes No
existing InterMiles membership number in this application form, a new InterMiles
membership number will be allotted to you and linked to your Credit Card. Please note You can opt out of such data sharing at any point of time by contacting Manchester
that by applying for the InterMiles ICICI Bank Credit Card you are consenting to the United (“MU”) at the address below. By signing up, you agree to MU Group using your
Terms and Conditions of membership of the InterMiles programme. These can be personal data in accordance with their Privacy Policy. MU uses your data to personalize
found at www.intermiles.com and improve your experience on their digital platforms, provide products and services
 I confirm to have read and understood the schedule of charges, and agree to be levied you request from them, and carry out profiling and market research. Please read Privacy
the applicable fees and charges for the Credit Card chosen by me Policy (which includes an updated list of MU Group companies & MU official sponsors
and partners) at http://www.manutd.com/ or for a copy write to the MU Data Protection
 I have not paid any cash or cheque for the Credit Card annual fee at the time of Officer at Manchester United Football Club Limited, Sir Matt Busby Way, Old Trafford,
application Manchester, M16 0RA.
 Issuance of the said Credit Card is at the sole discretion of ICICI Bank Ltd. The credit
limits on the Credit Card account will be fixed by the bank based on my income  1) I hereby authorise ICICI Bank Ltd ("ICICI Bank") to share my data or information
documents. associated with my MakeMyTrip ICICI Bank Credit Card ("Card application") (i) E-mail ID;
(ii) Mobile number; (iii) Card variant availed of (Platinum/Signature); (iv) Credit Card
 For cash withdrawals, interest will be charged from the day of the transaction and no account number with MakeMyTrip (India) Private Limited and its affiliates ("MMT") to
free credit period will be provided update its records and provide me services, rewards & benefits with respect to the Card
 Processing time: A minimum of 10 days. 2) I hereby agree that in case the e-mail ID provided by me in the Card application does
not have a corresponding MMT account, MMT shall provide me with services, rewards
 I am aware that as part of the bank's GoGreen initiative, the Credit Card Welcome Kit for
& benefits associated with the Card on my MMT account linked to my mobile number.
ICICI Bank Credit Cards has been digitised. The PDF copy of the membership guide,
In case my e-mail ID or mobile number are not present in any MMT account, MMT shall
Terms and Conditions and Most Important Terms and Conditions (MITC) is available for
create a new MMT account on my behalf with my e-mail ID and/or mobile number,
download at www.icicibank.com/cc-ewelcomekits. A physical copy of the same shall be
provided under the Card application. MMT shall update me with details of the new
made available by the bank upon request made by calling ICICI Bank's Customer Care.
MMT account and steps to access the new MMT account by way of an SMS and/or
 CREDIT LIMIT DECLARATION The Cardholder shall be entitled to apply for a e-mail. In case you require any further information regarding information disclosures,
review/enhancement/reduction of the Credit Limit and/or Cash Limit (if provided by please check ICICI Bank Card Terms and Conditions.
ICICI Bank), upon completion of 12 months of his/her membership. Alterations upon
such review, if any, of the Credit Limit and/or Cash Limit will be at the sole discretion of  For more information regarding information disclosures, please check ICICI Bank Card
ICICI Bank. ICICI Bank shall at its sole discretion be entitled to review (including Terms & Conditions.
enhancement or reduction) of the Credit Limit and/or Cash Limit assigned on the Card
at any time and only enhancements, if any, to the Credit Limit and/or the Cash Limit,
shall be effected by ICICI Bank with the consent of the Cardholder.

• I confirm that I have gone through all the Terms and Conditions, Most Important Terms & Conditions and Important Credit Card Declaration and hereby
agree to abide by the same.

• I hereby consent to receiving information from Central KYC Registry through SMS/e-mail on the above registered number/e-mail ID

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