Application Form 8310824008077

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Amazon Pay ICICI Bank Credit Card Application Form

PRIMARY APPLICANT
PHOTO
Joining Fee: NA Annual Fee*(2nd year onwards): NA

Overdue Interest on Extended Credit Interest on Cash Advances


Financial
Charges: Monthly Rate Annual Rate Monthly Rate Annual Rate
3.5% - 3.8% 42% - 45.6% 3.5% - 3.8% 42% - 45.6%

,
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*

Maiden Name(if any)

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*

Gender* ✔ M- Male F- Female Others

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

AZQPA1613G - Verified
Proof of Identity PAN Card
PROOF OF ADDRESS (PoA)*
CURRENT / PERMANENT ADDRESS DETAILS

Address Type* Residential/Business Residential Business Registered Office Unspecified


Proof of Address* Passport Driving Licence UID (Aadhaar) Voter’s Identity Card

Current Address * HOUSE NO 55, BONGAON

NEAR CHILDREN FOUNDATION SCHOOL

Landmark AT Road, Jorhat

City/Town/Village* SIBSAGAR Pin/Post code* 785107

State/U.T code* ASSAM

Country INDIA

Tel. (Resi.) 9707714707


Mobile (In India)

District* IN
ISO 3166 Country Code*

Permanent Residential Address* Khudrakuchi

Khudrakuchi

Landmark Barpeta

City/Town/Village* NALBARI Pin/Post code* 781319

State/U.T code* ASSAM

Country INDIA

Tel. (Resi.)
Mobile (In India) 9707714707
District*
ISO 3166 Country Code* IN

E-mail ID (Personal)* liakatali512@gmail.com

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*

STD code Tel. Mobile 9394852172

ABOUT YOUR WORK


Academic Qualification* Under Graduate Graduate / Diploma Holder ✔ Post Graduate Professional
Occupation Type* S-Service ( Private Sector Public Sector Government Sector )
Others ( Professional Self-employed Retired House wife Student )
B-Business X-Not Categorised
Company Name* JAWAHARLAL NEHRU HIGH SCHOOL

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

Others (Please specify) No. of year(s) in current business* NA

Type of Profession Doctor CA/CS Lawyer Architect Consultant Engineer Others (Please specify)

Designation* ASSISTANTTEACHER Department* Others

Employee ID ( mandatory if salaried) 111111 No. of year(s) in current job* Total experience (No. of years)*

Net Annual Income* Gross Annual Income*

Jawaharlal Nehru High School Komarkhatuwal Kakojan


Office Address*

Komarkhatuwal Kakojan

Landmark* Jorhat City / Town / Village* SIBSAGAR

State / U. T Code* ASSAM Pin / Post Code* 785107

STD code* 20 Tel* 11111111 EXT.* Mobile* 9707714707

Office E-mail ID* (Mandatory if salaried) JNHS@GMAIL.COM

District* ISO 3166 Country Code* IN


SUBSCRIPTION FOR CREDIT CARD VALUE ADDED SERVICES
Contact Address* ✔ Residence Office (Please select one option only)

I want to subscribe for* ✔ Statement by E-mail Mobile Alerts


liakatali512@gmail.com 9707714707
E-mail ID Mobile No.

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

IMPORTANT CREDIT CARD DECLARATION


 I/We declare that all the particulars and information given in the application form  ICICI Bank reserves the right to provide the Applicant with a card type based on
are true, correct, complete and up to date in all respects and I/we have not information available with ICICI Bank assessment of the Applicant’s credit rating.
withheld any information. I/We confirm that I/we have had no insolvency initiated
 I/We authorise ICICI Bank to exchange, share or part with all the information
against me/us nor have I/we ever been adjudicated insolvent. I/We have read the
relating to me/us and repayment history to credit bureaus, agencies, statutory
application form and brochures and am/are aware of all the terms/conditions of
bodies, market research agencies for conducting research as may be required and
availing finance, including but not limited to the Terms and Conditions and MITC,
shall not hold ICICI Bank (or market research agencies) liable for use/sharing of this
from ICICI Bank Limited (“ICICI Bank”). I/We authorise ICICI Bank to make
information.
references and enquiries related to information in this application which, ICICI
Bank consider necessary. I/We undertake to inform ICICI Bank regarding change in  I hereby authorize ICICI Bank Limited to share the data/information associated with
my/our residence/employment and to provide any further information that ICICI my Amazon Pay ICICI Bank Credit Card such as my application details and status,
Bank may require. account status, card number, reward details and activity data associated with
Amazon Pay (India) Private Limited and its affiliates to update its records and
 I/We understand that certain particulars given by me/us are required by the provide me services, rewards & benefits on my Amazon Pay ICICI Bank Credit Card.
operational guidelines governing banking companies. I note that if I wish to opt out of such sharing of data by ICICI Bank with Amazon Pay
 I/We declare that I/we have read the application form and brochure and am/are (India) Private Limited and its affiliates, I have the option to cancel my credit card at
agreeable to the terms/conditions of availing the Credit Card from ICICI Bank, any point of time by calling on toll free number: 1800 102 0123 ✔ Yes No
including but not limited to the Terms and Conditions and MITC.
 Subject to applicable law, if the arrangement between Amazon and ICICI Bank is
 I/We further agree to the terms governing the issuance of a Supplementary Card transferred to another bank/financial institution, at Amazon’s request, the
as specified in the Terms and Conditions governing the Credit Card. customer hereby consents to transfer of all data, information along with all
obligations and outstanding to such successor bank/financial institution.
 I/We declare and undertake that the Credit Cards issued to me/us, if used overseas,
shall be utilised strictly in accordance with the relevant exchange control  I/We understand that any change(s) in the Terms and Conditions governing this
regulations issued and as amended by the Reserve Bank of India (RBI) from time Credit Card facility will be communicated to me/us and will also be available to
to time. In the event I/we exceed my/our entitlements as per the exchange control me/us on request.
guidelines of RBI, I/we undertake to bring the same immediately to the notice of
 I/We have read and understood the Terms and Conditions governing this Credit
ICICI Bank in writing. Further, I/we also agree and understand that if I/we are
Card and MITC and agree to abide by them.
required to get my/our passport endorsed for any charges incurred by me/us as
stipulated by RBI, the onus of getting my/our passport endorsed shall lie entirely  The Applicant/s has/have no objection to ICICI Bank and ICICI Bank representatives
on me/us. In the event of any failure to comply with the prevailing exchange providing me/us with information on various products, offers and services
control guidelines issued by RBI by me/us, I/we shall be liable for any action under provided by ICICI Bank /third parties through any mode (including without
the Foreign Exchange Management Act, 1999, as amended from time to time and limitation through telephone calls/SMSs/ E-mails) and authorise ICICI Bank and its
be debarred from the Credit Card facility either at ICICI Bank instance or by RBI. representatives for the above purpose.
 In the event of a Credit Card program closure or at the time of renewal of Credit Please tick Yes or No, as acceptable to the Applicant/s. ✔ Yes No
Card, ICICI Bank at its sole discretion reserves the right to provide a card type that  ICICI Bank may also share Cardholder information with any parent, subsidiary,
is different from the existing card type held by the Cardholder. The Credit Limits affiliate or associate of ICICI Bank, for the purposes of marketing and offering
and Cash Limits on any Credit Card at any point in time are as per sole discretion various products and services of ICICI Bank or its group companies, subsidiaries,
of ICICI Bank. affiliates and/or associates.
 The Credit Card application shall continue to be valid for any replacement card Please tick Yes or No, as acceptable to the Applicant/s. ✔ Yes No
provided at the time of closure/renewal.
 Internationally valid Card and all other Cards cannot be used on Internet or
 I/We declare Except to the extent disclosed to ICICI Bank, no director or a otherwise for the purchase of prohibited items like lottery tickets, banned or
relative/near relation (as specified by RBI) of a director of a banking company proscribed magazines, participation in sweepstakes, payment for callback
(including ICICI Bank) or a relative/near relation (as specified by RBI) of a senior services, remittance in any form towards overseas forex trading, margin calls to
officer of ICICI Bank (as specified by RBI) is: the applicant(s), or a partner of our overseas exchanges/overseas counterparty, trading in foreign exchange in
concern, or a trustee, member, director, manager, employee of our concern, or of domestic/overseas markets including binary option trading with commodities,
our subsidiary, or our holding company, or a guarantor on my/our behalf, or holds stocks, indices, virtual currencies, bitcoin index and forex etc. ICICI Bank does not
substantial interest in our concern or my/our subsidiary or holding company. deal in virtual currencies or provide services to any person dealing in virtual
currencies in any manner, such services including maintaining accounts,
 I hereby give consent to ICICI Bank for linking my ICICI Bank credit card with my
registering, trading, settling, clearing, giving loans against virtual tokens, accepting
existing ICICI Bank savings/current account, if any. I understand that this would
them as collateral, opening accounts of exchanges dealing with them and transfer
enable me to access my ICICI Bank credit card account using the existing user ID
/ receipt of money in accounts relating to purchase/ sale of virtual currencies.
provided to me under my ICICI Bank savings/current account, if any, through
internet banking and iMobile facility. I provide consent to and authorize ICICI Bank  I/We declare that, in the event of change in address due to relocation or any other
to use the KYC details provided by me including but not limited to my Aadhaar reason, I would intimate the new address to ICICI Bank within 2 weeks of such a
card number for the aforesaid purpose. I further understand that I may delink my change.
ICICI Bank savings/current account from my ICICI credit card by calling ICICI Bank
 The documents submitted along with the Credit Card application form will be kept
Customer Care number available at www.icicibank.com.
with ICICI Bank for record purposes and may be returned upon written request by
the Applicant.
 I confirm to have read and understood the schedule of charges, and agree to be shall be made available by the ICICI Bank upon request made by calling ICICI
levied the applicable fees and charges for the Credit Card chosen by me. Bank's Customer Care.
 I have not paid any cash or cheque for the Credit Card annual fee at the time of  I hereby acknowledge and confirm that I have read and understood the Terms
application. and Conditions governing this Credit Card and available at ICICI Bank website
 Issuance of the said Credit Card is at the sole discretion of ICICI Bank. The Credit  The Cardholder shall be entitled to apply for a review/enhancement/reduction of
Limits on the Credit Card Account will be fixed by ICICI Bank based on my the Credit Limit and/or Cash Limit (if provided by ICICI Bank), upon completion
income documents. of 12 months of his membership. Alterations upon such review, if any, of the
Credit Limit and/or Cash Limit will be at the sole discretion of ICICI Bank. ICICI
 For cash withdrawals, interest will be charged from the day of the transaction Bank shall at its sole discretion be entitled to review (including enhancement or
and no free credit period will be provided. reduction) of the Credit Limit and/or Cash Limit assigned on the Card at any time
 Processing time: A minimum of 10 days. 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 am aware that as part of the ICICI Bank's GoGreen initiative, the Credit Card
 I authorise ICICI Bank Limited to provide me updates on my application and reach
welcome kit for ICICI Bank Credit Cards has been digitised. The PDF copy of the
out to me for information/offers relating to other products/services offered by
membership guide, Terms and Conditions governing Credit Card facilities (Terms
ICICI Bank Limited/its affiliates through Whatsapp. I acknowledge that I shall have
and Conditions) and Most Important Terms & Conditions (MITC) is available for
the right to stop receiving these communications on Whatsapp by clicking on ‘Block’
download at www.icicibank.com/cc- ewelcome-kits. A physical copy of the same
Please tick Yes or No, as acceptable to the Applicant/s ✔ “Yes” and “No”

Lead Generator EMP ID : Application Ref. No.* :

CRM ID : DMA Code : Promo Code : Lead Fulfiller EMP ID :

Channel Code :
AN Logo :
445 Company Code :
Branch SOL ID :

Application Type* New Update


(To be filled by financial institution) KYC Number (Mandatory for KYC update request)
Account Type* Normal Simplified (for low risk customers) Small

(,) LIAKAT ALI


IP and Coordinates ________________________ Name as per NSDL (PAN) _____________________________________________________________

DOCUMENT UPLOAD MATRIX

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

Utility bill which is not more than two months old

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)

Letter of accommodation from employer

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

Customer Consent One Pager

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