Application Form 8310824008077
Application Form 8310824008077
Application Form 8310824008077
PRIMARY APPLICANT
PHOTO
Joining Fee: NA Annual Fee*(2nd year onwards): NA
,
The interest rate will vary dynamically from 3.5% per month to 3.8% per month based on the customer’s behavior and performance.
ABOUT YOURSELF
Liakat
First Name*
Middle Name
Ali
Last Name*
Liakat Ali
Name to be printed on Credit Card*
31/10/1990
D D M M Y Y Y Y
Date of Birth* Place of Birth*
Father Name*
Spouse Name
Date of Birth* D D M M Y Y Y Y
ROMISA KHATUN
Mother Name*
AZQPA1613G - Verified
Proof of Identity PAN Card
PROOF OF ADDRESS (PoA)*
CURRENT / PERMANENT ADDRESS DETAILS
Country INDIA
District* IN
ISO 3166 Country Code*
Khudrakuchi
Landmark Barpeta
Country INDIA
Tel. (Resi.)
Mobile (In India) 9707714707
District*
ISO 3166 Country Code* IN
1
Type of Residence Bungalow Row House Flat 1 Others (Please Specify)
✔ Year(s) at current address
Residence Status* Owned Rented With parents Provided by Company With Relatives/Friends 1 Others (please specify)
✔
Meherjan Nessa
Family/Relative Reference 1 Name
Address
City* Pin*
Employer Details Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector Government Multinational Others (Please specify)
Nature of Business Manufacturing Trading Service Retailing Agriculture Stock Broker Real Estate
Type of Profession Doctor CA/CS Lawyer Architect Consultant Engineer Others (Please specify)
Employee ID ( mandatory if salaried) 111111 No. of year(s) in current job* Total experience (No. of years)*
Komarkhatuwal Kakojan
Alternate E-mail ID
I understand that under the alert facility, ICICI Bank Limited (“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 as provided by ICICI Bank in this regard, from time to time.
I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address
Channel Code :
AN Logo :
445 Company Code :
Branch SOL ID :
Photograph ✔
Identity Proof (any one of the documents) Passport Voter’s Identity Card Driving License ✔ Aadhaar Card
Address Proof (any one of the documents) Passport Voter’s Identity Card Driving License Aadhaar Card
Electricity Bill Piped Gas Bill Telephone Bill Post-Paid Mobile Phone
Water Bill
Property or Municipal tax receipt Pension or family pension payment orders (PPOs)
Registered License agreements along with recent utility bills not older than two months in
name of landlord