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    Certificate

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    preetmavi9872

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    © All Rights Reserved
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    Certificate

    Uploaded by

    preetmavi9872
    9 views7 pages

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    9 views7 pages

    Certificate

    Uploaded by

    preetmavi9872

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual

    For office use only Application Type * New KYC Modification KYC

    (To be filled in by financial institution) KYC Number 2450604 (Mandatory for KYC update request)

    KYC Mode * Online KYC Digilocker

    1. PERSONAL DETAILS
    Prefix First Name Middle Name Last Name

    Name* (Same as ID proof) MR HARPAL SINGH MAVI

    Maiden Name (If any*)

    Father / Spouse Name* MR HARWINDER SINGH

    Mother Name* MRS MALKIT KAUR

    Date of Birth* 04-04-1997 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

    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 Jurisdiction of Birth*

    3. PROOF OF IDENTITY (PoI) *


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

    A- Passport Number Passport Expiry Date – –


    B- Voter ID Card

    C- PAN Card EIAPM0915E


    D- Driving Licence Driving Licence Expiry Date – –
    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 *

    (Certified 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

    S- Simplified Measures Account - Document Type code

    Address
    Line 1* S/O HARWINDER SINGH,RADIALA,KHARAR,RADIALA,SAS
    Line 2 NAGAR(MOHALI,PUNJAB

    Line 3 City / Town / Village* SAS NAGAR MOHALI

    District* Pin / Post Code* 140301 State / U.T. Code* PB ISO 3166 Country Code* IN

    State* PUNJAB Country* INDIA

    4.2 CORRESPONDENCE / LOCAL ADDRESS DETAILS *

    Same as Current / Permanent / Overseas Address Details

    Line 1* S/O HARWINDER SINGH,RADIALA,KHARAR,RADIALA,SAS


    Line 2 NAGAR(MOHALI,PUNJAB

    Line 3 City / Town / Village* SAS NAGAR MOHALI

    District* Pin / Post Code* 140301 State / U.T. Code* PB ISO 3166 Country Code* IN

    State* PUNJAB Country* INDIA

    5. CONTACT DETAILS (All communications will be sent on provided Mobile no. / Email-ID)

    Tel. (Off) – Tel. (Res) – Mobile 91-9872605319

    FAX – Email ID PREETMAVI9872@GMAIL.COM

    7. APPLICANT DECLARATION
    I/We hereby declare that the KYC details furnished by me are true and correct to the best of my/our knowledge and belief and I/we
    under-take 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/We are aware that I/We may be held liable for it.I/We hereby consent to receiving information
    from CVL KRA through SMS/Email on the above registered number/Email address.I am/We are also aware that for Aadhaar OVD based
    KYC, my KYC request shall be validated against Aadhaar details. I/We hereby consent to sharing my/our masked Aadhaar card with
    readable QR code or my Aadhaar XML/Digilocker XML file, along with passcode and as applicable, with KRA and other Intermediaries
    with whom I have a business relationship for KYC purposes only

    I hereby consent consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email
    address.
    Date : 23-04-2024 Place : BANGALORE

    Signature / Thumb Impression of Applicant

    (SIGNATURE AS PRESENT IN PAYTM MONEY RECORDS)


    8. ATTESTATION / FOR OFFICE USE ONLY

    Documents Received Certified Copies

    KYC VERIFICATION / IPV CARRIED OUT BY


    INSTITUTION DETAILS
    Date 23-04-2024 Name PAYTM MONEY
    Name PAYTM MONEY Intermediary Details*

    Emp. Name VISHAK HEGDE


    Self certified document copies received (OVD)
    Emp. Code 39
    True Copies of documents received (Attested)
    Emp. Designation ASSOCIATE
    Emp. Branch PAYTM MONEY
    PROOF OF IDENTITY (PoI)
    PROOF OF ADDRESS (PoA)
    PROOF OF ADDRESS (PoA)
    Signature Details

    Name of the Customer HARPAL SINGH MAVI

    PAN Number EIAPM0915E

    Signature as per Paytm Money


    Records

    E Signature

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