KYC Form

KYC Form
A. Identity Details
1. Name of the Applicant

First NameLast Name
2. Father's/Spouse's Name

First NameLast Name
2a. Gender

MaleFemale
2b. Marital Status

SingleMarried
2c. Date of Birth

MonthDayYear
Date
3. Nationality
4. Status

Resident IndividualNon ResidentForeign National
5. PAN
6. Proof of Identity Submitted for PAN Exempt Cases

UIDPassportVoter IDDriving LicenseOther
B. Address Details
1. Address for Correspondence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
2. Phone Number
Please enter a valid phone number.
3. Email
example@example.com
4. Proof of Address to be Provided by Applicant

PassportRation CardDriving LicenseVoter Identity CardRegistered Lease/Sale Agreement of ResidenceLatest Bank Account Statement/PassbookLatest Telephone BillLatest Electricity BillLatest Gas BillOther
5. Permanent Address of Resident Applicant If Different From B1 Above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
6. Proof of Address to be Provided by Applicant

PassportRation CardDriving LicenseVoter Identity CardRegistered Lease/Sale Agreement of ResidenceLatest Bank Account Statement/PassbookLatest Telephone BillLatest Electricity BillLatest Gas BillOther
C. File Upload

Please upload related photographs and documents.
Cancelof
D. Declaration
I hereby declare that the information provided in this form is accurate and complete. I confirm that any information is found incorrect and/or incomplete that leads a violation of regulations may initiate legal actions, and I accept that I am the responsible party for any and all charges, penalties and violations.
Name of the Applicant

First NameLast Name
Signature of the Applicant

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Date Signed

MonthDayYear
Date
For Office Use Only
Originals verified and Self-Attested Document copies received
Name of the Authorized Signatory

First NameLast Name
Signature of the Authorized Signatory

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Date Signed

MonthDayYear
Date
Obsidian One Corp

KYC Form
Should be Empty:

KYC Form

A. Identity Details

B. Address Details

C. File Upload

D. Declaration

For Office Use Only

Obsidian One Corp