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Customer Name: M R . A N A N D A K U M A R K
Address: 7 3 , S H R I K R I S H N A K U T I R A , S A I S R U S H T I S A N G A
M A M , , B E H I N D T I T A N T O W N S H I P , H O S U R , T A M
I L N A D U , I N D I A , 6 3 5 1 1 0
Date of Birth 2 4 0 7 1 9 7 3
Communication Address :
There is no change in my mailing address I wish to change my mailing address as below.
House No. : Building Name:
Building Level.: Street No: Street Name:
Land Mark: Locality:
Country :
City: State: PIN code : (Please specify if
other than India)
E-mail ID :
I wish to update my contact details as below.
Tel No.:STD Code (R) (O)STD Code: (O)
Mob.No. : PAN: UID
(Aadhar No:)
Permanent Address :
House No. : Building Name:
Building Level.: Street No: Street Name:
Land Mark: Locality:
Country :
City: State: PIN code : (Please specify if
other than India)
E-mail ID :
Customer Profile
1. Occupation:
a. If Salaried, employed with : Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector
Government Multinational Others
b. If Self Employed, and
If in Business, nature of Business : Manufacturing Trading Services Retailing Agriculture Multilevel Marketing
Stock Broker Real Estate Shroff / others
Money lender
If Professional, type of Profession: Doctor CA/CS Lawyer Architect Consultant
Engineer Others
c. If Others : Housewife Retired Student
d. If Agri Allied /Farmer, details of landholding : Nil <= 5 acres >5 acres
2. Education : Under Graduate Graduate Post Graduate Professional
3. Gross Annual Income Nil < 1 lakh 1 lakh - 5 lakh 5 lakh - 10 lakh 10 lakh - 15 lakh
15 lakh - 20 lakh 20 lakh - 25 lakh 25 lakh - 50 lakh 50 lakh - 1 Cr >1Cr
L A S T
Mob.No. : PAN :
Permanent Address :
House No. : Building Name:
Customer Profile
1. Occupation:
a. If Salaried, employed with : Proprietorship Partnership Pvt. Ltd. Public Ltd. Public Sector
Government Multinational Others
b. If Self Employed, and
If in Business, nature of Business : Manufacturing Trading Services Retailing Agriculture Multilevel Marketing
Stock Broker Shroff / others
Money lender
If Professional, type of Profession: Doctor CA/CS Lawyer Architect Consultant
Engineer Others
c. If Others : Housewife Retired Student
d. If Agri Allied /Farmer, details of landholding : Nil <= 5 acres >5 acres
2. Education : Under Graduate Graduate Post Graduate Professional
3. Gross Annual Income Nil < 1 lakh 1 lakh - 5 lakh 5 lakh - 10 lakh 10 lakh - 15 lakh
15 lakh - 20 lakh 20 lakh - 25 lakh 25 lakh - 50 lakh 50 lakh - 1 Cr >1Cr
Customer Declaration :
I /We declare, confirm and agree to inform ICICI Bank regarding any changes in my/our residence / communication address and to provide new address to the Bank within
two weeks of such change
I/We hereby authorize the Bank to update my/our Bank account/s and any other facilities product/s held by me/us with the Bank, basis the details provided by me/us in this
form.
Signature Signature
Paste a recent passport size Paste a recent passport size
photograph here duly signed across photograph here duly signed across
(35 mm x 35 mm) (35 mm x 35 mm)
(Name:-____________________________) (Name:-____________________________)
Notes: 1. The address on this form should be as in supporting documents. 2. If there are more than one joint account holders, use photocopies of this form. 3. The submitted data
is valid for all account numbers held under your Customer
Basic Statistical Return (BSR) code: (For Joint account holders, to be filled by Bank official)
Occupation Male Female
Agri Allied/Farmer 41141 41142
(Landholding Nil, <= 5 acres, > 5 acres)
Business 41241 41242
(Manufacturing, Trading, Service, Retailing, Agriculture, Real Estate)
Professional
(Doctor, CA/CS, Lawyer, Architect, Consultant, Engineer)Housewife, Retired, Student
Business 41141 41142
(Shroffs/Moneylenders, Stock Brokers, Dealers in Bullion)
Salaried 41341 41342
(Proprietorship, Partnership, Pvt. Ltd, Public Ltd, Public Sector, Government, Multinational, Wage Salary earners, others)
Others (Please Specify) I also confirm that the form has been signed and filled by the applicant in my presence.
DVU done by :
Employee Number : Designation of the Bank Official __________________________ Name of Employee __________________________
Acknowledgement to Customer
Customer Name M R . A N A N D A K U M A R K
Branch Seal