INDIVIDUAL

CUSTOMER RELATION FORM

THIS FORM WILL PASS THROUGH A SCANNER,PLEASE FILL IN BLOCK LETTER E.G ANITA KUMAR

Application : Commercial Vehicle Light Commercial Vehicle Construction Equipment Gold Loan Rural Housing
Tractor Finance Crop Loan Housing Finance Loan against Property Unnati
Business Loan Working Capital Personal Loans Agri Finance Credit Card

PERSONAL DETAILS BORROWER CO-BORROWER GUARANTOR * Fields are Mandatory

*Existing CRN Yes,If yes then provide the CRN no. 663259579 NO Home Branch Code

*CKYCR Create New Existing(No Change) Update Existing Local Global

local change will not be updated in central KYC Repository(CKYCR) and will only be applicable to Kotak Mahindra Bank Limited

*Name MOHAMMAD HUSAIN MUS SHAIKH

Name as a desired on the credit card MOHAMMAD SHAIKH *DOB 1/3/2000

*Mother's Name MARYAM Maiden Name MARYAM

(Mention Mother's Pre-Marriage Name) (applicable to married woman,documentary proof required)

*Father / *Spouse Name *Citizenship Indian Others

(If PAN not available Father's Name Mandatory)

*Residential Status Residential Indian Foreign Nation Non Resident Indian Person of Indian Origin
*Education Non-Graduate Graduate Post-Graduate Others

*Religion Hindu Muslim Christian Sikh Zoroastrian Jain Buddhist Others

*Gender M *Marital Status Single Married Others Single

*Caste *Category General OBC SC ST

*Annual Income 0-2 lakhs > 2-5 lakhs > 5-10 lakhs > 10-25 lakhs > 25 lakhs 0
*Occupation Type Service ( Private Sector Public Sector Government Sector ) Not Categorised Business

Others ( Professional Self Employed Retired Housewife Student Student

Permanent/ Indian Address (Upto 90 Characters Only)

Line 1 BORLI PANCHTAN

Line 2 .

Line 3 / Landmark BORLI PANCHTAN

*City / Town / Village RAIGAD *PIN Code 402403

*State Maharashtra *Country India Telephone No.

Residence (Upto 90 Characters Only) Same as Permanent Address

Residence Status: Owned By Self By Parents Rented With Friends With Family Years at Current Residence

Line 1 Rajhans building thane

Line 2 5th floor flat no 502
Line 3 / Landmark Thane West 400604
*City / Town / Village THANE *PIN Code 400604
*State Maharashtra *Country India Telephone No.

Office Address (Upto 90 Characters Only)

Line 1 Rajhans builing
Line 2 THANE west
Line 3 / Landmark Near by railway station
*City / Town / Village THANE *PIN Code 400604
*State *Country India Telephone No.
Preferred Mobile No. 8446659858 Alternative Mobile no.
Preferred Email-Id husainsk615@gmail.com

*Preferred Correspondence Address Permanent Address Residence Address Office Address Office
CUSTOMER DECLARATION

I/We hereby declare that the above information is true and correct to the best of my/our knowledge. I/We further agree that any false/misleading information given by me/us
or suppression of any material fact will result in withholding declining of the transaction by the Bank and I/we may be held liable for it. I/We hereby confirm that the
transaction made by me/us is from my / our own source of funds acquired legitimately and it is not in contravention or evasion of any applicable laws or rules in force,
enacted/issued by Statutory or Regulatory Authority from time to time. I/We, authorise the Bank to share my / our transaction details with regulatory/enforcement authorities
whenever such information is called for. I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email
address.I understand that as per directions of Government of India, my KYC information will be updated in Central KYC Registry & I hereby authorise the Bank to open my
account in the same name as registered with UIDAI for issuing Aadhar / Income Tax for issuance of PAN. I also confirm that either of the name as appearing in the above
noted two databases will supersede with name as mentioned in the Account Opening Form.

SIGNATURE / THUMB IMPRESSION & PHOTOGRAPH

DOCUMENTS COLLECTED DETAILS

Document Name ID Address Document Name ID Address

(only one id and address proof mandatory) Proof Proof (Cont.) Proof Proof
Passport Number Simplified Documents No.

Passport Expiry Date Identity card with applicant's photograph issued by

Govt. Dept.
Voter ID Card Letter issued by a Gazetted Officer NA
PAN OREPS7433G NA Simplified Documents (Address Proof)
Utility Bill
Driving License
Property or Municipal Tax Receipt
Driving License Expiry Date Bank account statement / Passbook NA
Pension or family pension payment orders(PPOs)
E-UID(AADHAR)
Letter of allotment of accommodation from employer
NAREGA Job Card issued by state or Central Government departments
Others (any document notified by the Central Documents issued by Govt. Dept. of Foreign
Government) Jurisdiction / Foreign Embassy / Mission in India
Document Name:
Number:

NAME DECLARATION

I Mr. / Mrs. / Ms. , state and declare that many of my official records bear my
name as since I am also known by this name. I say that I desire to open a loan/credit card account with you under the
name and style of , although the documents submitted by me are bearing my name as . I request
you therefore to open the account with your bank on my aforesaid representation as per the form duly filled in by me and accept the documents furnished by me
in support thereof.

Signature

BANK USE

Key Verification carried out by Approved by

DD MM YYYY Emp. Code Emp. Branch
Sales Official (Sign & Code)Branch Official (Sign & Code)
Emp. Name
Employee Sign
Emp. Designation Designation Designation

Account Type Normal Simplified Small Risk Profile High Medium Low Customer Segment RA CC
CRN No. Apac No. Form No.
Other Documents Collected Form 60 Marriage Certificate
 Application Form for Kotak Credit Card Kotak Mahindra bank Ltd.

THIS FROM IS PASS THROUGH SCANNER,PLEASE FILL IN BLOCK LETTERS E.G

MOHAMMAD HUSAIN MUS SHAIKH
FORM NUMBER

CM74363141

I want to apply for a Kotak League RuPay

Credit card

Tick Box Joining Fees Annual Fees

0 0

Key Features:

Get 4 free PVR tickets or 10,000 Reward Points on spends of Rs.1,25,000 every 6 months
Link with UPI and transact seamlessly
Earn up to 8X Reward Points on every Rs.150 spent across all categories
Already have a Kotak Credit Card? Total spends on all your cards will be capped at the highest credit l

Applicant Signature

ABOUT ME

Name of the Company NA

Department Company Code (For Bank use only)

Designation Telecaller
Whether Director of any Bank: Yes No If yes,Name of the Bank
If Salaried: Total Work Experience Years If Self Employed: Total Duration in Business Years
Ownership: Proprietorship Partnership Pvt. Ltd. Company HUF

Type of Vehicle: Four Wheeler Two Wheeler Both None

Think Green; Save the Environment. Say no to paper statement. I consent to receive only e-statements on the email address.

Industry Section IT / Software / BPO Infrastructure / Real Estate Export / Import Trading / Retailing
Advertising / Marketing / Media / Publication Manufacturing Travel / Transport / Courier / Cargo Freelancer / Consultancy
Verification / Collection / DSA / DST HR / Security Services Legal Services Spare Parts / Accessories
Government / PSU / NGO Banking / Finance Medical / Healthcare Professional Services
Others (Please specify)

MY BANK DETAILS

MAIN BANK DETAILS

Name of Bank
Account Number Branch

Account Type Saving Current Other (Please specify)

Customer Relationship Number

Incase you have a Kotak account

APAC ID PARTY ID

MY CREDIT CARD DETAILS

Name of the Bank

Card Number Member Since MM YY Credit Limit

LOAN DETAILS

Loan Account Number

Issuing Bank/Branch Type of Loan MM YY

I WANT THE AUTO DEBIT FACILITY

I authorise Kotak Mahindra Bank to debit my Kotak Mahindra Bank

Account No. every month for
Minimum Amount Due Total Amount Due

I WANT AN ADD-ON CARD

Name of the Add-On Card Application

CRN of the Add-On Card Application (If has a Kotak Account)

Name as desired on the Card ( Max 19 Characters ): MOHAMMAD SHAIKH

Date Of Birth Gender Male Female

Relationship with Primary Card Holder : Spouse Parent Brother/Sister (above 18y of age) Child (above 18y of age)

I would like to restrict the spending limit on the Add-On Card to: Rs. 10,000 Rs. 20,000 Same as my primary card

Contact details of Add-On Card Holder

Residence No.. STD. Code: Tel. No.

Mobile Number

APAC ID PARTY ID

Email ID

I aceept that the use of the Add-On Card is governed by the acceptance of the card number aggrement.
I accept the complementary Add-On Card.
 Primary Applicant Signature

OVER-LIMIT CHARGES

Accepted true

I wish to avail over limit facility on my Kotak Credit Card. I understand that this facility allows transactions to get approved above assigned credit limit, to meet my emergency needs and it’s at Bank’s discretion. I also
understand that bank will levy charges & fees, as applicable, in case of over limit utilization.

Applicant Signature

ONEASSIST PROGRAM

Your wallet is protected 24x7,

whether you lose it or not!

One call from anywhere in the world

Block all lost Bank Cards
Emergency travel and hotel assistance
Fraud protection
Block lost SIM card
Docusafe: Free online storage for your
documents

I hereby authorize Kotak Credit Cards to debit the amount indicated below:

PRICES*

Annual

Please tick the appropriate plan

* The above prices are inclusive of Government taxes
(including service tax, GST, any/all applicable taxes from time to time)

Applicant Signature

Yes, I hereby agree and accept to purchase the OneAssist Program on my Kotak Credit Card. I hereby agree that the above declaration shall be the basis on my admission to
OneAssist Program on approval of my Kotak credit card application and if found untrue or is misleading or any material information is withheld here form, no claim under this coverage
will be payable by OneAssist Consumer Solutions Pvt Ltd. I authorize OneAssist Consumer Solutions Pvt. Ltd.(OneAssist) and Kotak Mahindra Bank Ltd.(KMBL) to charge the amount
indicated above and subsequent annual payments when due to my Kotak Credit Card at the prevailing rate, until this authorization is revoked or withdrawn by me in recorded line to
OneAssist. I authorize KMBL to disclose, from time to time, any information relating to my card(s) as KMBL may deem fit and proper to OneAssist for the purpose of issuance and
administration of the OneAssist Program membership. I also authorize OneAssist/ KMBL to contact me over riding my NDNC registry. I understand that the OneAssist Program is a
product from OneAssist Consumer Solutions Private Ltd. and KMBL does not endorse the offer, nor is it liable for any loss, claim or damage arising out of usage of the product.

CARD PROTECTION PROGRAM

Protect more than just your cards-your peace of mind!

One free call to block all cards

24 hours helpline
Emergency travel and hotel assistance
 Fraud protection
PAN Card Replacement
SIM Card Blocking

I hereby authorize Kotak Credit Cards to debit the amount indicated below:

PRICES*

Annual

Please tick the appropriate plan

*The above prices are inclusive of Government taxes
(including service tax, GST, any/all applicable taxes from time to time)

Applicant Signature

Yes, I hereby agree and accept to purchase the Card Protection Program on my Kotak Credit Card. I hereby agree that the above declaration shall be the basis on my admission to
Card Protection Program membership on approval of my Kotak credit card application and if found untrue or is misleading or any material information is withheld here form, no claim
under this coverage will be payable by CPP Assistance Services Private Limited (CPP). I authorize CPP and Kotak Mahindra Bank Ltd. (KMBL) to charge the amount indicated above to
my Kotak Credit Card and subsequent annual payments when due at the prevailing rate until this authorization is revoked or withdrawn by me in recorded line to CPP. I authorize KMBL
to disclose, from time to time, any information relating to my card(s) as KMBL may deem fit and proper to CPP for the purpose of issuance and administration of the Card Protection
Program membership. I also authorize CPP/KMBL to contact me over riding my NDNC registry. I understand that the Card Protection Program is a product from CPP and KMBL does not
endorse the offer, nor is it liable for any loss, claim or damage arising out of usage of the product.

SIGN UP & DECLARATION

Date
Applicant Signature
Name

FOR BANK USE

Promo Code: Fee Code:

NPQ1 111
Channel Code Source Code
CM93
CSM Code : Card Sales Executive:

Referrer's Emplopyee Code Other Card Saled Executive:

Employee Group Code: Cross Sell Tracker:

Employee Code: Cross Sell Reference No:

Branch Code

INDICATIVE LIST OF DOCUMENTS THAT CAN BE PROVIDED WHILE APPLYING FOR CREDIT CARD

Identity Proof:
• Passport • Driving Licence • PAN Card • Valid Photo Credit/Debit Card issued by Banks ­ Only if the Photo and signature are imprinted on the front of the Card •
Voter's ID card Identity document issued by government and/or Statutory/Regulatory body if photo included) Bank passbook Active accounts) with photograph
only of scheduled commercial banks only along with the bank seal/stamp and signature of the bank official. (Updated not more than 3 months old) Aadhar Card

Signature Proof:
• Passport • Driving Licence • PAN Card Valid Photo Credit/Debit Card issued by Banks ­ Only if the Photo and signature are imprinted on the front of the Card
Identity document issued by government and/or Statutory/Regulatory body (if signature included)

Residence Proof:
• Passport • Driving Licence Voter's ID card • PAN intimation Letter • Ration Card • Identity document issued by government and/or Statutory/Regulatory body (if
address included) • Utility Bill (Elec./Tele./Mobile/Piped Gas/Water bill/Broadband bill not more than 3 months old for bank account). Original and photocopy
statements allowed. E­statements should be PDF printouts. • Credit Card Statement not more than 2 months old. F­statement should be PDP printouts. •
Registered Leave & license agreement (For tenants) ­ Letter from Housing Society (Only for owners) with latest 2 moths Maintenance Bill • Sale deed • Bank
Statement (Active Account) - signed & stamped o with logo/printed by Bank and not more than 2 months old. F-statements should be PDF printout with logo of
the bank. Bank passbook (Active accounts) of schedule commercial banks only along with the bank seal/stamp and signature of the bank official. (Updated not
more than 3 months old) Gas Connection Copy (Front Page of the booklet signed of by a PSU Official) with computerized gas bill not more than 3 months 3
old/photocopy of gas connections copy showing cylinder purchases not more than 3 months old Aadhar Card

Check your application status:

VISIT www.kotak.com | SMS CCAPP < space > application reference number> to 5676788

FORM NUMBER

CM74363141

FORM NUMBER
CM74363141

I, the undersigned have applied for a Kotak Credit Card from Kotak Mahindra Bank Limited (hereinafter referred to as the "Bank") and in connection with my Application,
have submitted various documents and information to the Bank. am aware that the Bank and its group companies / associates offer various other products and
services and I would like to be informed about the various products services offered by the Bank and its group companies / associates. For this purpose, the Bank may
need to share my documents / information l across group companies / associates.

I hereby expressly authorise the Bank to exchange, share, disclose, or use in any manner whatsoever, any and or all information / document provided by me to the
Bank with its group companies! associates and to make telephone calls and! or send SMS's and / or emails and / or use any other form of communication to offer and
or market and or sell to me any of the products or services or any enhancements / upgradation/ revisions thereof offered from time to time, by the Bank or its group
companies / associates.

Applicant Signature

KOTAK MAHINDRA BANK LIMITED