Account Opening Form

1. TYPE OF ACCOUNT : I wish to open the following type of account SB Basic savings Bank deposit Account
2. NATURE OF ACCOUNT : OTHER INDIVIDUAL
3. FULL NAME, in CAPITAL Letters(leaving a space between first, middle & last name) Customer Photo :
Reference No K330286011332009122401000096 Image Preview
Customer Name ARNAB MONDAL
Sex Male
Account No 1133201700034403
Customer ID R51625481
Aadhaar No XXXXXXXX7148
Mobile No 9547865934
4. Mode of Operation : SELF
5. ADDRESS :
Flat No./Bldg. Name
Street / Road / Locality S/O Bharati Mondal,, Purba Madhabpur, CONTA, WEST BENGAL, 721453
City / District / State with pincode
Tel.No / Fax No.(with STD code) 9547865934
Email
6. CUSTOMER PROFILE :
Date of Birth 16-12-2013
Educational Qualification --- SELECT ---
Nationality INDIAN
Category OTHERS/GENERAL
Religion HINDU
PAN / GIR no(if not available, please fill form 60 / 61 at 12)
Occupation Type STUDENT
Designation / Profession Student
Annual Income < 60000
Annual turnover / Receipt from business(Rs. Lakh)
Classification *
Name of Father / Guardian CHAITANYA MONDAL
Marital Status SINGLE
Name of Spouse (if married)
7. KNOW YOUR CUSTOMER (KYC) DOCUMENTS :
ID Proof Address Proof
Type of document UIDAI UIDAI
Document ID No. XXXXXXXX7148 XXXXXXXX7148
Issuing Authority UIDAI UIDAI
Place of Issue
Date of Issue
Valid up to
I attach the copies of documents opted for and produce the original copies of these documents for verification.
8. Nomination :

I want to nominate as under

Name of the Date of Birth in case of Person authorised in case of minor to receive the amount of deposit on behalf of the nominee in event of my / minor's death during the
Relationship Age
nominee minor minority of nominee.
BHARATI
MOTHER
MONDAL
Date:
Place: Signature of declarant
WITNESS IN CASE OF NOMINATION (FOR THUMB IMPRESSION ONLY)

Name & Signature of the first witnesses Name & Signature of the second witnesses
Name:- Name:-
Signature:- Signature:-
Address:- Address:-
To be filled by those who do not have either PAN/GIR: (Select appropriate form)
Form No. 61
Form No. 60
To be filled by a person who has agricultural income and is not in receipt of any other income chargeable to
To be filled by person without PAN
income tax
1. Are you assessed to tax? Yes No
I hereby declare that my source of income is from agriculture and i am not required to pay income-tax on
2. If yes (i) Details of ward/Circle/Range where the last return of income was filed_________
any other income, if any.

Declaration

I ARNAB MONDAL do hereby declare that what is stated is true to the best of my knowledge and belief.

Date:
Place: Signature of declarant

Declaration/Undertaking
a) Please seed my Aadhaar / UID Number issued by UIDAI. I hereby give my consent to the Bank to use my Aadhaar details to authenticate me from UIDAI by using my biometrics for the purpose of
Bank account.
b) I declare that I am desirous of receiving entitled benefits or subsidies of welfare schemes funded from the Consolidated Fund of India in my account directly.
c) I also hereby give my consent to Bank for enabling AePS facility : Yes.
d) I hereby give my consent to download my KYC Records from the Central KYC Registry (CKYCR), only for the purpose of verification of my identity and address from the database of CKYCR
Registry. I understand that my KYC Record includes my KYC Records /Personal information such as my name, address, date of birth, PAN number etc.
Date:
Place: Signature of declarant

For Official Use:

Specimen Photograph
Signature /
Thumb
impression of
the customer

Name Signature GBPA / PF No Date

Rupay Debit Card issued
Signature Verified
Account Verified
Registration of Nomination
Punjab National Bank
(Authorized Official) Name_______________GBPA No____________