Know Your Customer Personal Form

Photo
Date -ldlt_ D D M M Y Y Y Y (P.P.size)

Branch -zfvf_

Account No. -vftf g+=_

Identification Details/ kl/ro ljj/0f

Account Holder Name -vftfjfnsf] gfd_
In English

b]jgfu/Ldf
Citizenship No. Date of Issuance: D D M M Y Y Y Y
Place of Issuance
gful/stf g+= hf/L u/]sf] ldlt hf/L u/]sf] :yfg
Passport No. Date of Issuance: D D M M Y Y Y Y
Place of Issuance
/fxbfgL g+= hf/L u/]sf] ldlt hf/L u/]sf] :yfg
In case of Indian national and refugee -ef/tLo gful/s tyf z/0ffyL{sf] xsdf_
Reg./ID Card No. Date of Issuance: D D M M Y Y Y Y
Place of Issuance
btf{÷kl/rokq g+= hf/L u/]sf] ldlt hf/L u/]sf] :yfg
Other ID Card Type ID Card No.
cGo kl/rokqsf] lsl;d kl/rokq g+=
Date of Issuance: D D M M Y Y Y Y
Issuing Authority
hf/L u/]sf] ldlt hf/L ug]{ lgsfo
Date of Birth D D M M Y Y Y Y
Nationality Self PAN No.
hGd ldlt /fli6«otf cfgf] :yf= n]= g+=
Details of Family Members (As Applicable) / kfl/jfl/s ljj/0f

S.No. Relationship / gftf Name, Surname / gfd, y/ Remarks / s}lkmot

1. Spouse / bDklt
2. Father / lktf
3. Mother / dftf
4. Grand father / afh]
5. Grand mother / xh'/ cfdf
6. Son / 5f]/f
7. Daughter / 5f]/L
8. Daughter-in-law / a'xf/L
9. Father -in-law* / ;;'/f
Note: Please use additional sheet if required. / cfjZos ePdf cltl/Qm k[i7 k|of]u ug'{xf]nf . * In case of married women only. / ljjflxtf dlxnfsf] xsdf .

Address / 7]ufgf
Current Address -xfnsf] 7]ufgf_
House No. -3/ g+=_ Ward No. -j8f g+=_ Street/Tole -;8s÷6f]n_
Municipality/VDC -gkf÷uflj;_ District -lhNnf_ Tel No. -6]=g+=_
Fax No. -km\ofS; g+=_ Mobile -df]afO{n_ Email -Od]n_

Permanent Address -:yfoL 7]ufgf_

House No. -3/ g+=_ Ward No. -j8f g+=_ Street/Tole -;8s÷6f]n_
Municipality/VDC -gkf÷uflj;_ District -lhNnf_ Tel No. -6]=g+=_
Fax No. -km\ofS; g+=_ Mobile -df]afO{n_ Email -Od]n_
 Transaction Volume / sf/f]af/sf] dfqf
Purpose of Account Maximum Amount per Transaction
vftfsf] k|of]hg clwstd /sd k|lt sf/f]af/
Details / ljj/0f Number / ;+Vof Amount / /sd

Estimated Monthly Transactions / cg'dflgt dfl;s sf/f]af/

Estimated Annual Transactions / cg'dflgt aflif{s sf/f]af/

Location Map of Residential Address of account holder

vftfjfnsf] j;f]af; ug]{ 7]ufgfsf] dfu{ lrq
N

(Please mention nearest prominent landmark like temple/department store/school etc.)

-s[kof glhssf] dlGb/÷:s'n h:tf s'g} vf; :yfg÷j:t' sf] lrGx pNn]v ug'{xf]nf_
Note: In case of change in address, the bank must be informed immediately and the location map updated accordingly.
gf]6M j;f]jf; ug]{ 7]ufgf kl/j{tg ePdf a}+snfO{ t'?Gt gof“ 7]ufgfsf] gS;f ;d]t hfgsf/L u/fpg' kg]{ .

Detail of Income Source / cfo ;|f]t ljj/0f

For Salaried Employee / tnaL sd{rf/Lx?sf] nflu
S.No. Name of Employer Organization (In order of recent to last) Address Designation Annual Salary
qm=;+= sfo{/t ;+:yfsf] gfd -kl5Nnf]af6 cl3Nnf] qmddf_ 7]ufgf kb jflif{s tna
1

Note: Please use additional sheet as required. / cfjZos ePdf cltl/Qm kfgf k|of]u ug'{xf]nf .

For Self-employed / Business / :j/f]huf/ Joj;fosf] nflu

S.No. Name of Organization PAN Address Designation Annual Income
qm=;+= ;+:yfsf] gfd :yf= n]= g+= 7]ufgf kb jflif{s cfo
1

2
Note: Please use additional sheet as required. / cfjZos ePdf cltl/Qm kfgf k|of]u ug'{xf]nf .
If other sources of income please specify Annual Income
cfDbfgLsf] cGo ;|f]t ePdf s[kof v'nfpg'xf];\ jflif{s cfo
For Students / ljBfyL{sf] nflu
S.No. Name of School / College Address Telephone No.
qm=;+= ljBfno ÷ SofDk;sf] gfd 7]ufgf kmf]g g+=
1

2
 Please tick “” the appropriate box(es) for each of the following questions: Yes No
-tn pNn]lvt k|Zgx?sf] pko'Qm sf]i7df lrGx nufpg' xf];\_ xf] xf]Og
Are you a U.S. Resident? -s] tkfO{ cd]l/sfsf] afl;Gbf x'g'x'G5 <_

Are you a U.S. Citizen? -s] tkfO{ cd]l/sfsf] gful/s x'g'x'G5 <_

Do you hold a U.S. Permanent Resident Card (Green Card)? -s] tkfO{ cd]l/sL Green Card k|fKt JolQm x'g' x'G5_

Do you have beneficial owner? -s] tkfO{sf] lxtflwsf/L x'g'x'G5<_

YES NO

If yes, please write name of beneficial owner and relationship with you.
-5 eg] tkfO{sf] lxtflwsf/Lsf] gfd / tkfO{;+usf] gftf v'nfpg'xf];\ ._

S.No. Name Relation Address Contact No.

qm=;+= gfd ;DaGw 7]ufgf ;Dks{ g+=
1

I we/hereby declare that all the information provided are true and correct. In case of information not available
with me/us or not applicable to me/us, the same has been specifically mentioned in the respective section of
this form.
d÷xfdL n] pknAw u/fPsf ljj/0fx? l7s / ;fFrf] x'g\ . d÷xfdL ;Fu gePsf ljj/0fx? cyjf d÷xfdL ;Fu ;DalGwt gePsf ljj/0fx? olx kmf/dsf]
tf]lsPsf v08x?df pNn]v ul/Psf] 5÷5f}+ .

..................................................................
A/c Holder Signature -vftfjfnsf] b:tvt_

For Bank's Use Only

Account Risk Grading: High Risk Low Risk Medium Risk

Reason for Risk Grading

............................................... ...............................................
Authorized Person Authorized Person
Name Name
Date Date