CENTRAL CKYC REGISTRY | Know Your Customer (KYC) Application Form | Individual

IMPORTANT INSTRUCTIONS

  1. Fields marked with '*' are mandatory fields.
  2. Tick (✔) wherever applicable.
  3. Please fill the form in English and in BLOCK letters.
  4. Please fill the date in DD-MM-YYYY format.
  5. For particular section update, please tick (✔) in the box section number and strike off the sections not required to be updated.
  6. Please read section wise detailed guidelines/instructions at the end.
  7. List of State/U.T code as per Indian Motor Vehicle Act, 1988, is available at the end.
  8. List of two character ISO 3166 country codes is available at the end.
  9. KYC number of applicant is mandatory for update application.
  10. The 'OTP-based E-KYC' check box is to be checked for accounts opened using OTP based E-KYC in non face to face mode.
cersai logo
FOR OFFICE USE ONLY

(to be filled by financial institution)

Application Type*

KYC Number

(Mandotary for KYC Update Request)

Account Type*

1. PERSONAL DETAILS

(Please refer to Instruction A at the end)

Prefix

First Name

Middle Name

Last Name

Name

* (same as ID proof)

Maiden Name

Father/Spouse Name

Mother Name

Date of Birth*

PAN*

Form 60 furnished

Gender*

Marital Status*

Nationality*

Residental Status*

2. PROOF OF IDENTITY AND ADDRESS*

(Please refer to Instruction B at the end)

l.

Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be submitted (any one of the following OVDs)

PHOTO*


ADDRESS

Line 1*
Line 2
Line 3
City/Town/Village*
District*
Pin/Post Code*
State/U.T. Code*
ISO 3166 Country Code

3. CURRENT ADDRESS DETAILS

(Please refer to Instruction B at the end)
l. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be submitted (any one of the following OVDs)

ADDRESS

Line 1*
Line 2
Line 3
City/Town/Village*
District*
Pin/Post Code*
State/U.T. Code*
ISO 3166 Country Code

4. CONTACT DETAILS

(All communications will be sent to Mobile number/Email ID provided) (Please refer to Instruction C at the end)
Tel. (Off)
Tel. (Res)
Mobile
Email ID

5. REMARKS

(if any)

6. APPLICATION DECLARATION

  • I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake 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 aware that I may be held liable for it.

  • I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address.

Place


SIGNATURE(S2)

7. ATTESTATION/FOR OFFICE USE ONLY

Document Received

IPV Done

on

KYC VERIFICATION CARRIED OUT BY

Date
Emp. Name
Emp. Code
Emp. Designation
Emp. Branch

Employee Signature

INSTITUTION DETAILS

Name
Shriram Insight Share Brokers Ltd.
Code
IN0349

Institution Stamp