Regd. Office : TJSB House, Plot No.

B-5,
Road No.2, Wagle Estate, MIDC, Thane (W)-400604.
Ph.: 2587 8500

Date : 17-02-2025 Branch : SYNDICATE BRANCH

(Photo)
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Customer No. 69215 Account No. 006010100015468

First Name Middle Name Last Name

Name* (Same as ID proof) MR GURURAJ BABURAO KANJIKER

Father Name* MR BABURAO BALWANTRAO KANJIKER
MRS GEETA
(Father’s name is mandatory if ‘PAN’ is not furnished)

Spouse Name
GURURAJ KANJIKER
Mother’s Maiden Name*
MRS SULOCHANA

Date of Birth* 0D D7 0 3M
M 1Y 9Y 6Y 7Y
Gender* M- Male F- Female T-Transgender
Marital Status* Married Unmarried Others

Nationality* IN- Indian Others (ISO 3166 Country Code )

Residential Status* Resident Indian Non Resident Indian

Foreign National Person of Indian Origin

Address Line 1
1 SEEMA VIHAR CHS

Line 2
THANGE WADI

Line 3
NR SNET THOMAS SCHOOL KALYAN WEST

MAHARASHTRA KALYAN
State / U.T Code City / Town / Village

421301 Pin / Post Code ISO 3166 Country Code

PAN No.
AHSPK8585F Aadhaar No.
599849171600

Passport No. Annual Income

LESS THAN 10L

Occupation Type* S-Service ( Private Sector Public Sector Government Sector Retired )
O-Others ( Professional Self Employed Business )
Work place/Employer Name & Address :

705-707 NYATI EMPORIOUS

Line 1

Line 2
BANER
PUNE
Line 3

MAHARASHTRA PUNE
State / U.T Code City / Town / Village
411045 ISO 3166 Country Code
Pin / Post Code

Housewife Student

X- Not Categorised Pl. Specify _________________________________________

(P.T.O.)
 Regd. Office : TJSB House, Plot No.B-5,
Road No.2, Wagle Estate, MIDC, Thane (W)-400604.
Ph.: 2587 8500

ISO 3166 Country Code of Jurisdiction of Residence*

* (If issued by jurisdiction)*

PAN/TIN (Tax Identification No.) PAN/ TIN Issuing Country Expiry Date Documents provided #
/Functional Equivalent /Functional Equivalent issuing Country

Place / City of Birth*

BIDAR ISO 3166 Country Code of Birth*

# Self attested copy of documentary evidence for TIN/Functional Equivalent and tax residency should be mandatorily provided.

3. PROOF OF IDENTITY (PoI)*

(Certified copy of any one of the following proof of Identity [PoI] needs to be ticked)

A- Passport B- Voter ID Card C- PAN Card D- Driving Licence E- UID (Aadhaar) F- NREGA Job Card
Z- Others (pl. specify) -

Type : Ownership Rental

Address Type* Residential / Business Residential Business

Passport Driving Licence UID (Aadhaar)
Voter Identity Card NREGA Job Card Others

17-02-2025 SIGNATURE*
(with Rubber Stamp)

PUNE GURURAJ BABURAO KANJIKRT

ATT ESTATION / FOR OFFICE USE ONL Y

Documents Received - True Copies Notary Risk Category High Medium Low
IN PERSON VERIFICATION CARRIED OUT BY INSTITUTION

Identity / Introduction Verification Date D D M M Y Y Y Y Name TJSB SAHAKARI BANK LTD.

Emp. Name Code IN 0860
Emp. Code
Emp. Designation
Emp. Branch Bank
Seal
[Employee Signature]
Manager’s Signature
Obtain personal KYC for Joint Account Holder(s)