7/21/2019 Know Your Customer

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 Know Your Customer (KYC) Form (Request

ID: 19006813)

1) Personal Details Name Of Consumer*

Salutation (Mr./Ms./Mrs/Miss)*: MR.First Name*: SURESH

Middle Name: NAME!

"ast Name*: #URA!

#as Consumer Num$er: 

(Onl% for e&istin' ustomers)ate Of irt*: +,--+00 

(-MM-1111)

 Name of istri$utorsi2: A3E4 #AS SER!5CE ( ++,6+ )

Fater7s Name*: NAME! S2ouse Name : SAN85!AN5

Moter7s Name: SU#ANA

) !""ress #or $P% &onne&tion ' Conta&t In#ormation3roof Of Address (3OA)

3OA Cate'or%: 3OA9 - "ease A'reement 3OA etail: #H3#,6"

House/Flat;< Name : #ANESH CHA Floor No : N5"

Housin' Com2le&/uildin' : #O"5AR  "and Mar= : SAN>ACRU?

EAS>

Street/Road Name : >H ROA

Cit%/>o@n/!illa'e: MUMA5 35N Code: 6B

istrit : MUMA5 SUURAN State : Maarastra

Mo$ile No : 00B006B06 "andline :

Email 5: starentre.in'mail.om

3) ter Rele*ant Details3roof Of 5dentit% (3O5)

3O5 Cate'or%: 3O59 - 3AN CAR Num$er Card Num$er: #H3#,6"

Ration Card etails if ADaila$leState Of 5ssue: Maarastra Ration Card Num$er:

+) ,an- Details

an=Name: ena an=  5FSC/M5CR/5NN:N+,

Aount >%2e: SaDin's Aount No:+,+B0,6+

 Name As 5n Aount: SURESH

De&laration: 5 ere$% delare tat te information 2roDided $% me a$oDe is true and orret to te $est of m%=no@led'e and $elief. 5 also onfirm tat in te eDent of an% information 2roDided $% me is found inorret / is

inom2lete and also in te eDent of an% Diolation of #oDernment Re'ulation related to te su22l% and distri$ution of 

"3#< 3C @ill $e @itin its ri't to disontinue su22l% of "3# %linders to me< forfeit of seurit% de2osit and an

leD% 2enal ar'es as 2er te 2oli% and 'uidelines and ma% initiate le'al ation a22lia$le under 2roDisions.

5 also onfirm tat 5 do not aDe an% o$etion in reeiDin' SMS from 3C" on te mo$ile num$er 'iDen in tis

form.

.ame / inature : Date:

2o e #ille" 4 Dealer'Distriutor

5 onfirm aDin' Derified te 2otoo2ies of douments a$oDe a'ainst teir ori'inals.

7/21/2019 Know Your Customer

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Consumer Num$er (5f allotted):

inature o# Distriutor

!P5 %! 5R7IC5Date:

2ear ## 5/Ge< ere$%< onfirm reei2t of dul% filled in 1C form alon' @it releDant 3O5< 3OA douments form

 Name MR. SURESH NAME! #URA! Consumer no (if a22lia$le) on (date)

inature an" eal o# Distriutor