PHOTO HERE

RIM No.: :‫ر ﻗ ﻢ اﻟ ﻤﻠ ﻒ‬

Date: 21-10-2024 : ‫ا ﻟﺘﺎ رﯾ ﺦ‬

Branch Name / Code: 3 : ‫ ر ﻣ ﺰ ا ﻟﻔ ﺮ ع‬/ ‫ا ﺳ ﻢ‬

Account Details ‫ﺑـﯿـﺎﻧـﺎت اﻟﺤﺴﺎب‬

Full Name: PAWANA KUMARI : ‫ا ﻻ ﺳ ﻢ ا ﻟ ﻜﺎ ﻣ ﻞ‬
Family Name: KUMARI : ‫ا ﺳ ﻢ ا ﻟ ﻌﺎﺋ ﻠ ﺔ‬
Gender: F :‫اﻟ ﺠﻨ ﺲ‬
Passport Number: V2327696 : ‫ر ﻗ ﻢ ﺟ ﻮ ا ز ا ﻟ ﺴﻔ ﺮ‬
Expiry Date: 08-09-2031 : ‫ﺗﺎ رﯾ ﺦ اﻧﺘ ﮭﺎ ء ا ﻟ ﺼ ﻼ ﺣﯿ ﺔ‬
Nationality: India :‫اﻟ ﺠﻨ ﺴﯿ ﺔ‬ Previous Nationality: : ‫ا ﻟ ﺠ ﻨ ﺴ ﯿ ﺔ ا ﻟ ﺴ ﺎ ﺑﻘ ﺔ‬
Other Nationality: :‫ﺟﻨﺴﯿﺔ ٓاﺧﺮى‬
Country of birth: India :‫ﺑﻠ ﺪ اﻟ ﻤﯿ ﻼ د‬ Date of birth: 20-04-1981 : ‫ﺗﺎ رﯾ ﺦ ا ﻟ ﻤﯿ ﻼ د‬
Address: :‫اﻟ ﻌﻨ ﻮا ن‬ P.O. Box: :‫ﺻﻨ ﺪ و ق اﻟﺒ ﺮﯾ ﺪ‬
Prefered Account Language: en : ‫ﻟ ﻐ ﺔ ا ﻟ ﺤ ﺴﺎ ب‬
Account type requested: CURRENT : ‫ﻧ ﻮ ع ا ﻟ ﺤ ﺴﺎ ب ا ﻟ ﻤ ﻄ ﻠ ﻮ ب‬
Hawala Trading: NO : ‫ﻧ ﺸﺎ ط ا ﻟ ﺤ ﻮ ا ﻟ ﺔ‬
Screening Matches: No Match :‫ﻧﺘﯿ ﺠ ﺔ اﻟﺘ ﺤ ﺮ ي‬
PEP: Not Applicable : ‫ﺷ ﺨ ﺺ ﻣ ﺸﺘ ﻐ ﻞ ﻓ ﻲ ا ﻟ ﺴﯿﺎ ﺳ ﺔ‬

Account Services ‫ا ﻟ ﺨ ﺪ ﻣ ﺎ ت ا ﻟ ﻤ ﺼ ﺎ ﺣ ﺒ ﺔ ﻟﻔ ﺘ ﺢ ا ﻟ ﺤ ﺴ ﺎ ب‬
Telephone Banking Services: Yes / ‫ﻧﻌﻢ‬ : ‫ا ﻟ ﺨ ﺪ ﻣ ﺎ ت ا ﻟ ﻤ ﺼ ﺮ ﻓ ﯿ ﺔ ا ﻟ ﮭ ﺎ ﺗﻔ ﯿ ﺔ‬
Internet Banking Services: Yes / ‫ﻧﻌﻢ‬ : ‫ا ﻟ ﺨ ﺪ ﻣﺎ ت ا ﻟ ﻤ ﺼ ﺮ ﻓﯿ ﺔ ﻋ ﻦ ط ﺮﯾ ﻖ اﻧﺘ ﺮﻧ ﺖ‬
SMS Banking Services: Yes / ‫ﻧﻌﻢ‬ : ‫ﺧ ﺪ ﻣ ﺔ ا ﻟ ﺮ ﺳ ﺎ ﺋ ﻞ ا ﻟﻘ ﺼ ﯿ ﺮ ة‬
Cheque Book (for Current
No / ‫ﻻ‬ : ) ‫د ﻓﺘ ﺮ ﺷﯿ ﻜﺎ ت ( ﻟ ﻠ ﺤ ﺴﺎ ب ا ﻟ ﺠﺎ ر ي‬
Account):
Reason for use: :‫ﻏ ﺮ ض ا ﻻ ﺳﺘ ﺨ ﺪا م‬
Debit Card: Yes / ‫ﻧﻌﻢ‬ : ‫ﺑ ﻄﺎ ﻗ ﺔ ا ﻟ ﺨ ﺼ ﻢ ا ﻟ ﻤﺒﺎ ﺷ ﺮ‬
Cash Takaful Protection Service: No / ‫ﻻ‬ : ‫ﺧ ﺪ ﻣ ﺔ ا ﻟ ﺤ ﻤ ﺎ ﯾ ﺔ ا ﻟ ﺘ ﻜ ﺎ ﻓ ﻠ ﯿ ﺔ ﻟ ﻠ ﺴ ﺤ ﻮ ب ا ﻟ ﻨﻘ ﺪ ﯾ ﺔ‬

Name to be printed on Debit Card: : ‫ا ﻻ ﺳ ﻢ ﻛ ﻤﺎ ﺗ ﻮ د طﺒﺎ ﻋﺘ ﮫ ﻋ ﻠ ﻰ ﺑ ﻄﺎ ﻗ ﺔ ا ﻟ ﺨ ﺼ ﻢ ا ﻟ ﻤﺒﺎ ﺷ ﺮ‬

PAWANA KUMARI

Preferred mode of receiving

Email ‫اﻟﺒ ﺮﯾ ﺪ اﻟ ﻜﺘ ﺮ وﻧ ﻲ‬ : ‫ا ﺳﺘ ﻼ م ﻛ ﺸ ﻮ ﻓﺎ ت ا ﻟ ﺤ ﺴﺎ ب ﺑ ﻮ ا ﺳ ﻄ ﺔ‬
account statements:
Mode of delivery of Debit Courier ‫اﻟﺒ ﺮﯾ ﺪ اﻟ ﺴ ﺮﯾ ﻊ‬ ‫ د ﻓ ﺘ ﺮ‬/ ‫ط ﺮ ﯾﻘ ﺔ ا ﺳ ﺘ ﻼ م ﺑ ﻄ ﺎ ﻗ ﺔ ا ﻟ ﺪ ﻓ ﻊ ا ﻟ ﻤ ﺒ ﺎ ﺷ ﺮ‬
Card / Cheque book: : ‫ا ﻟ ﺸﯿ ﻜﺎ ت‬
Service Delivery Method: ATM Service (Cash/Cheque Deposit), Internet Banking, Mobile Banking : ‫ط ﺮ ﯾﻘ ﺔ ﺗﻘ ﺪ ﯾ ﻢ ا ﻟ ﺨ ﺪ ﻣ ﺔ‬
Relation Initiation Method: Digital Channels : ‫ط ﺮ ﯾﻘ ﺔ ﺑ ﺪ ء ا ﻟ ﻌ ﻼ ﻗ ﺔ‬

Personal Details ‫اﻟﺒـﯿـﺎﻧـﺎت اﻟﺸـﺨﺼﯿﺔ‬

Country: ARE :‫اﻟﺒﻠ ﺪ‬
Emirate: Dubai : ‫ا ﻣﺎ ر ة‬
Address: AL STA b20 :‫اﻟ ﻌﻨ ﻮا ن‬
P.O. Box: :‫ﺻﻨ ﺪ و ق اﻟﺒ ﺮﯾ ﺪ‬
Current Address: Tel. No. : ‫ا ﻟ ﻌﻨ ﻮ ا ن ا ﻟ ﺤﺎ ﻟ ﻲ‬
: ‫ر ﻗ ﻢ ھﺎﺗ ﻒ ا ﻟ ﻤﻨ ﺰ ل‬
(home):
Mobile No.: 971526183159 : ‫ر ﻗ ﻢ ا ﻟ ﮭﺎﺗ ﻒ ا ﻟ ﻤﺘ ﺤ ﺮ ك‬
Email Address: pawanakumaridxb@gmail.com :‫اﻟﺒ ﺮﯾ ﺪ اﻟ ﻜﺘ ﺮ وﻧ ﻲ‬

I.D. Type: Emirates ID :‫ﻧ ﻮ ع اﻟ ﮭ ﻮﯾ ﺔ‬

I.D. Number: 784198117611180 :‫ر ﻗ ﻢ اﻟ ﮭ ﻮﯾ ﺔ‬

Date of issue: : ‫ﺗﺎ رﯾ ﺦ ا ﺻ ﺪ ا ر‬

Expiry Date: 20-06-2026 : ‫ﺗﺎ رﯾ ﺦ ا ﻻﻧﺘ ﮭﺎ ء‬

Employment Details ‫ا ﻟﺒﯿﺎﻧﺎ ت ا ﻟ ﻤ ﮭﻨﯿ ﺔ‬

Employment Type: EMPLOYED : ‫ﻧ ﻮ ع ا ﻟ ﻮ ظ ﯿﻔ ﺔ‬
EmployerName: A ARAS MEDICAL DEVICES AND EQUIPMENT CO LL :‫ﺟ ﮭ ﺔ اﻟ ﻌ ﻤ ﻞ‬
P.O. Box: :‫ﺻﻨ ﺪ و ق اﻟﺒ ﺮﯾ ﺪ‬

Tel. No. (office): : ‫ھﺎﺗ ﻒ ا ﻟ ﻌ ﻤ ﻞ‬

Employer Address: : ‫ ا ﻟ ﺸ ﺮ ﻛ ﺔ‬/ ‫ﻋﻨ ﻮ ا ن ﺻﺎ ﺣ ﺐ ا ﻟ ﻌ ﻤ ﻞ‬

Sector: PRIVATE_SECTOR_EMPLOYEE : ‫ﻗ ﻄﺎ ع‬
Joining Date: : ‫ﺗﺎ رﯾ ﺦ ا ﻟﺘ ﻌﯿﯿ ﻦ‬
Job Title: Salesman : ‫ا ﻟ ﻤ ﺴ ﻤ ﻰ ا ﻟ ﻮ ظ ﯿﻔ ﻲ‬

Monthly Salary: 5500 :‫اﻟ ﺮاﺗ ﺐ اﻟ ﺸ ﮭ ﺮ ي‬

 Are you a US Resident/ Green card holder/ Tax resident in US?
No, I confirm that I am not
US TAX DECLARATION

I/we hereby declare and confirm that all documents & information submitted to ADIB are current, valid and binding. In the event of expiry or invalidity of any of the
submitted documents it shall be my sole responsibility to promptly provide ADIB with the latest versions of the submitted documents. I acknowledge and understand that
ADIB shall bear no responsibility or liability for any consequences whatsoever that may result from my failure to provide ADIB with the latest versions of the submitted
documents and I assume liability for all such consequences. I/we undertake to inform ADIB in writing with any changes of information immediately. Also, I/we hereby
consent for ADIB or any of its affiliates to share my/our information with domestic and overseas Regulators and tax authorities where necessary.

Customer's Digital Signature

Cash Transactions
Number of incoming transactions: 5

Total incoming transaction 3300

amount:
Number of outgoing transactions: 15

Total outgoing transaction amount: 2750

Cross Border Transactions

Number of incoming transactions: 1

Total incoming transaction 550

amount:
Number of outgoing transactions: 5

Total outgoing transaction amount: 550

Other Transactions
Number of incoming transactions: 10

Total incoming transaction 5500

amount:
Number of outgoing transactions: 10

Total outgoing transaction amount: 2750

Customer Declaration ‫ٕاﻗﺮار اﻟﻌﻤﯿﻞ‬

I/we hereby declare and confirm that all documents & information submitted to ADIB
are current, valid and binding. In the event of expiry or invalidity of any of the
submitted documents it shall be my sole responsibility to promptly provide ADIB with
the latest versions of the submitted documents. ‫ وﻓﻲ ﺣﺎل اﻧﺘﮭﺎء او ﻋﺪم ﺳﺮﯾﺎن ا ٔي ﻣﻦ اﻟﻮﺛﺎﺋﻖ اﻟﻤﻘﺪﻣﺔ‬،‫ ﻧﺆﻛﺪ ﺑﺄن ﻛﺎﻓﺔ اﻟﻤﻌﻠﻮﻣﺎت واﻟﻮﺛﺎﺋﻖ اﻟﻤﻘﺪﻣﺔ ﻟﻤﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ ﺗﻌﺘﺒﺮ ﺳﺎرﯾﺔ وﺻﺤﯿﺤﺔ وﻣﻠﺰﻣﺔ‬/ ‫ ﻧﺤﻦ و ا ٔو ٔﻛﺪ‬/ ‫ ﻧﻘﺮ ا ٔﻧﺎ‬/‫ا ٔﻗﺮ‬
I/we acknowledge and understand that ADIB shall bear no responsibility or liability for .‫ ﻣﺴﺆوﻟﯿﺘﻨﺎ اﻟﻤﻨﻔﺮدة ﺗﺰوﯾﺪ ﻣﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ ﻋﻠﻰ اﻟﻔﻮر ﺑﺄﺧﺮ اﺻﺪارات ﻣﻦ ﺗﻠﻚ اﻟﻤﺴﺘﻨﺪات‬/‫ﻓﺴﯿﻜﻮن ﻣﻦ ﻣﺴﺆوﻟﯿﺘﻲ‬
any consequences whatsoever that may result from my failure to provide ADIB with the ‫ ﻧﺘﻔﮭﻢ ﺑﺄن ﻣﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ ﻟﻦ ﯾﺘﺤﻤﻞ ا ٔي ﻣﺴﺆوﻟﯿﺔ ا ٔو اﻟﺘﺰام ي ﺗﺒﻌﺎت ﻣﻦ ا ٔي ﻧﻮع ﻛﺎن ﻗﺪ ﺗﻨﺠﻢ‬/‫ ﻧﻘﺮ وا ٔﺗﻔﮭﻢ‬/‫ﻛﻤﺎ ا ٔﻗﺮ‬
latest versions of the submitted documents and I/we assume liability for all such .‫ ﻧﺘﺤﻤﻞ ﻣﺴﺆوﻟﯿﺔ ﻛﻞ ھﺬه اﻟﺘﺒﻌﺎت‬/ ‫ ا ٔﻧﻨﺎ ا ٔﺗﺤﻤﻞ‬/ ‫ ٕاﺧﻔﺎﻗﻨﺎ ﻓﻲ ﺗﻘﺪﯾﻢ ا ٔﺧﺮ ٕاﺻﺪارات اﻟﻤﺴﺘﻨﺪات اﻟﻤﻘﺪﻣﺔ ﻟﻤﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ وا ٔﻧﻨﻲ‬/ ‫ﻋﻦ ٕاﺧﻔﺎﻗﻲ‬
consequences. ‫اﻟﺨﺎﺻﺔ‬،‫ﻧﺆﻛﺪا ٔﻧﻨﯿﻘﺮا ٔﺗﻮﻓﮭﻤﺘﻮواﻓﻘﺘﻌﻠ ﺎﺣﻜﺎﻣﻮاﻟﺸﺮوطﺎﻟﻤﻮﻗﻌﺔﻣﻌﻤﺼﺮﻓﺎ ٔﺑﻮظﺒﯿﺎﺳﻼﻣﻲ‬/‫ﻛﻤﺎا ٔو ّٔﻛﺪ‬
‫ ﻛﻤﺎ‬.‫ﻧﺘﻌﮭﺪﺑﺈﻋﻼﻣﻤﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ ﺑﺸﻜﻞ ﻛﺘﺎﺑﻲ ﻋﻦ ا ٔي ﺗﻐﯿﯿﺮات ﻓﻲ اﻟﻤﻌﻠﻮﻣﺎت وﺑﺼﻮرة ﻓﻮرﯾﺔ‬/‫ا ٔﺗّﻌﮭﺪ‬.‫ﻋﻠﻤﺎ ٔﻧﻨﯿﺤﺼﻠﺘﻌﻠ ﻨﺴﺨﺔﻣﻨﮭﺎ‬،‫ﺑﺎﺗﻔﺎﻗﯿﺔاﻟﺨﺪﻣﺎﺗﺎﻟﻤﺼﺮﻓﯿﺔوا ٔﻧﻨﯿﺴﺄﻟﺘﺰﻣﺒﮭﺎ‬
I/we further confirm that I/we have read, understood and accepted, and will abide by the
‫ﻧﻮاﻓﻖ ﺑﻤﻮﺟﺐ ھﺬه اﻟﻮﺛﯿﻘﺔ ﻋﻠﻰ ا ٔن ﯾﻘﻮم ﻣﺼﺮف ا ٔﺑﻮظﺒﻲ اﺳﻼﻣﻲ ا ٔو ا ٔي ﻣﻦ ﺷﺮﻛﺎﺗﮫ اﻟﺘﺎﺑﻌﺔ ﺑﻤﺸﺎرﻛﺔ ﻣﻌﻠﻮﻣﺎﺗﻨﺎ ﻣﻊ اﻟﺴﻠﻄﺎت اﻟﺘﻨﻈﯿﻤﯿﺔ اﻟﻤﺤﻠﯿﺔ واﻟﺪوﻟﯿﺔ وﻏﯿﺮھﺎ ﻣﻦ اﻟﺴﻄﺎت‬/‫ا ٔواﻓﻖ‬
terms and conditions for the Banking Service Agreement (BSA) signed with Abu Dhabi
. ‫ا ﻟ ﺮ ﺳ ﻤ ﯿ ﺔ ا ﻟ ﻤ ﺨ ﺘ ﺼ ﺔ ﺑﺎ ﻟ ﻀ ﺮ ا ﺋ ﺐ ﻋ ﻨ ﺪ ا ﻟ ﻠ ﺰ و م‬
Islamic Bank, a copy of which was received by me I/we undertake to inform ADIB in
writing with any changes of information immediately. Also, I/ we hereby consent for
ADIB or any of its affiliates to share my/our information with domestic and overseas
Regulators and tax authorities where necessary.

Legal statement ‫ٕاﻗﺮار ﻗﺎﻧﻮﻧﻲ‬

The Customer acknowledges and confirms that the contact details provided by him/her to the Bank are correct,
accurate, complete and up to date. In the event of any missing information in this Account Opening Form, the ‫ وﻓﻲ ﺣﺎل ﻧﻘﺺ ﺑﻌﺾ اﻟﻤﻌﻠﻮﻣﺎت ﻓﻲ طﻠﺐ ﻓﺘﺢ‬،‫ﯾﻘﺮ اﻟﻤﺘﻌﺎﻣﻞ وﯾﺆﻛـﺪ ﺑﺄن ﺑﯿﺎﻧﺎت اﻻﺗﺼﺎل اﻟﺘﻲ ﻗﺎم ﺑﺘﺰوﯾـﺪ اﻟﻤﺼـﺮف ﺑﮭﺎ ﺻـﺤﯿﺤﺔ ودﻗﯿﻘﺔ وﻛﺎﻣﻠﺔ وﻣﺤﺪﺛﺔ‬
Customer hereby acknowledges and consents that the Bank may use any contact details provided by the Customer ‫ ﯾﻘﺮ اﻟﻤﺘﻌﺎﻣﻞ وﯾﻮاﻓﻖ ﻋﻠﻰ ا ٔن اﻟﻤﺼـﺮف ﻗﺪ ﯾﺴﺘﻌﻤﻞ ا ٔي ﺑﯿﺎﻧﺎت اﺗﺼﺎل ﻣﺘﻮﻓﺮة ﻓﻲ ﺳﺠﻼت اﻟﻤﺼﺮف ﻗﺎم اﻟﻤﺘﻌﺎﻣﻞ ﺑﺘﺰوﯾﺪ اﻟﻤﺼﺮف ﺑﮭﺎ ﺑﻤﺎ ﻓﯿﮭﺎ‬،‫اﻟﺤﺴﺎب‬
including but not limited to, registered email address and postal address (residential and correspondence) or his/ ‫ ا ٔرﻗﺎم اﻟﮭﺎﺗﻒ ا ٔو اﻟﻤﺤﻤﻮل ﻟﻠﺘﻮاﺻﻞ‬/‫ ﻋﻨﻮان اﻟﺒﺮﯾﺪ اﻟﻜﺘﺮوﻧﻲ وﺻـﻨﺪوق اﻟﺒﺮﯾﺪ اﻟﻤﺴﺠﻞ (اﻟﺸﺨﺼﻲ واﻟﺨﺎص ﺑﺎﻟﻌﻤﻞ) و رﻗﻢ‬،‫ﻋﻠﻰ ﺳﺒﯿﻞ اﻟﻤﺜﺎل ﻻ اﻟﺤﺼـﺮ‬
her mobile and/or telephone number(s)to contact the Customer for the purpose of obtaining such missing . ‫ﻣ ﻊ ا ﻟ ﻤ ﺘ ﻌﺎ ﻣ ﻞ ﺑ ﻐ ﺮ ض ا ﻟ ﺤ ﺼ ﻮ ل ﻋ ﻠ ﻰ ھ ﺬ ه ا ﻟ ﻤ ﻌ ﻠ ﻮ ﻣﺎ ت ﻣ ﻦ ﺧ ﻼ ل ﻣ ﻜﺎ ﻟ ﻤﺎ ت ھﺎ ﺗ ﻔ ﯿ ﺔ ﻣ ﺴ ﺠ ﻠ ﺔ‬
information through a voice recorded calls.

Customer Account Opening Form Acceptance Logs

Device
Event Date & Time Device Model Device Id Device IP
OS
2024-10- Samsung SM- 48a507a2-bdc8-3e70-b570-
OTP_HAS_BEEN_VALIDATED Android 10.6.81.19
21T23:55:47.769523 S908U 843b4e85bd73
2024-10- Samsung SM- 48a507a2-bdc8-3e70-b570-
OTP_HAS_BEEN_SENT Android 10.6.81.19
21T23:55:24.237545 S908U 843b4e85bd73
2024-10- Samsung SM- 48a507a2-bdc8-3e70-b570-
ACCEPTED Android 10.6.81.19
21T23:54:53.414956 S908U 843b4e85bd73