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 K330286011332026092401000024 Image Preview
Customer Name Nupur Singha
Sex Female
Account No 1133201700032928
Customer ID R49667011
Aadhaar No XXXXXXXX5466
Mobile No 7797468263
4. Mode of Operation : SELF
5. ADDRESS :
Flat No./Bldg. Name
Street / Road / Locality C/O: Hrishikesh Singha,, Gopalchak, CONTA, WEST BENGAL, 721423
City / District / State with pincode
Tel.No / Fax No.(with STD code) 7797468263
Email
6. CUSTOMER PROFILE :
Date of Birth 14-10-1991
Educational Qualification MATRICULATE
Nationality INDIAN
Category OTHERS/GENERAL
Religion HINDU
PAN / GIR no(if not available, please fill form 60 / 61 at 12) QMVPS9707R
Occupation Type HOUSEWIFE
Designation / Profession House Wife
Annual Income < 60000
Annual turnover / Receipt from business(Rs. Lakh)
Classification *
Name of Father / Guardian HRISHIKRSH SINGHA
Marital Status MARRIED
Name of Spouse (if married) PRABIR SINGHA
7. KNOW YOUR CUSTOMER (KYC) DOCUMENTS :
ID Proof Address Proof
Type of document UIDAI UIDAI
Document ID No. XXXXXXXX5466 XXXXXXXX5466
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 minority of
Relationship Age
nominee minor nominee.
SANDIP SINGHA SON
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 income
To be filled by person without PAN
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 any other
2. If yes (i) Details of ward/Circle/Range where the last return of income was filed_________
income, if any.

Declaration

I Nupur Singha 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____________