Know Your Customer (UFMIC ONLINE FORM) Application For m

(For Individuals Only) (Please fill in ENGLISH and in BLOCK LETTERS with black ink)
Resident Individual
1.

Non-Resident Individual Foreign National

Name of Applicant / Customer (As appearing in supporting identification document) Mr./Mrs./Ms./

Gender

Other

Name
(First Name)
2.
3.

(Middle Name)

Fathers Name (Mandatory) _

Date of Birth

5.

Country of Birth

6.

Nationality: Italian

8.

(Middle Name)

(Surname)

(First Name)

(Middle Name)

(Surname)

Minor

Senior Citizen
Place of Birth

Other (Specify)

Passport No. :

Date of Issue:
Date of Expiry:

Place of Issue:

Valid Visa (Mandatory- NRI / Diplomat / Foreign National):

Type of Visa:
Place of Issue

9.

(First Name)

PHOTOGRAPH
Please a f f ix the
recent passport
Size photograph and
sign acros s it.

Mothers Maiden Name (Mandatory)

4.

7.

(Surname)

Date of Issue: Date of Expiry:

Election ID Driving License Diplomat ID

No:

10. Permanent Address:

Flat No:

Building Name:

Street:

Locality:

City:

Poster Code:

Landline No:

State:

Country:

State:

Country:

_ Mobile No:

11. Correspondence / Mailing Address:

Flat No:

Building Name:

Street:

Locality:

City:

Poster Code:

Landline No:

_ Mobile No:

E-mail ID:

12. Gross Annual Income: (Please select anyone of the appropriate slab EUR / USD / GBP)
EUR Up to EUR 12,000-30,000 EUR 30,001-50,000 EUR 50,001- 75,000 EUR 75,001-120,000 above EUR 120,000 USD
Up to USD 12,000-30,000 USD 30,001-50,000 USD 50,001- 75,000 USD 75,001-120,000 above USD 120,000 GBP
Up to GBP 12,000-30,000 GBP 30,001-50,000 GBP 50,001- 75,000 GBP 75,001-120,000 above GBP 120,000
Others

(Specify):

13. Occupation: (Please Tick)

Retired

Bullion

Student Service

Diplomat Money Service

Real Estate

Jewelry / Diamond / Gems Precious Stones

Self Employed

Business

Professional

Others

(Please Specify)

Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd. /Public Sector/Govt./MNC/Staff ADCB)

Other

(Please Specify)

14. Qualification: Under Graduate Graduate Post Graduate Others

15. Source of Funds: Salary Business Inheritance Investment Other
16. FATCA Details
Are you a US Citizen (Green Card or Us Passport Holder)? Are
you liable to pay taxes in the US?
* If yes, to any of the above points 1) or 2), provide the latest W-8-BEN / W-9 form as applicable.

(Please Specify)
(Please Specify)
Yes No
Yes No

A) Tax Identification Number (TIN):

B)

TIN Issuing Country:

C) U.S Taxpayer Identification Number (SSN or ITIN):

D) Foreign Tax Identification Number:
17. Please tick, if applicable:

Politically Exposed Person Related to Politically Exposed Person

Politically Exposed Persons (PEP): PEPs are individuals who are or have been entrusted with prominent public functions in a
foreign country. Examples of PEPs include, but, not limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii)
government/judicial (iv) Senior executives of state-owned corporations (v) important political party officials (vi) Senior Indian
Diplomatic personnel posted outside the country. The term PEP also include the families and close associates of the PEPs
mentioned. Families: The families include close family members such as spouses, children, parents and siblings and may also include
other blood relatives and relatives by marriage. Close associates: The term closely associated persons in the context of PEPs
includes close business and personal advisors / consultants to the PEP as well as persons who obviously benefit significantly from
being close to such a person.

DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief. 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
confirm that the details submitted above are for updating the Bank's records and abide by Terms and Conditions as applicable from
time to time. I agree and undertake to notify the Bank within 30 days if there is a change in any information which I have provided
to the Bank.
Place:

Date:

Signature of Applicant / Customer