Please fill in ENGLISH and in BLOCK LETTERS. All fields are mandatory.

The information is sought under Prevention of Money Laundering Act, 2002, the rules notified thereunder and the Reserve Bank of India (RBI) guidelines on Anti Money Laundering and in view of the Policy Guidelines for issuance and operation of Prepaid Payment Instruments in India issued by RBI, relevant for issuance of prepaid vouchers.

KNOW YOUR CUSTOMER (KYC) FORM

Full Name of the Customer
(as appearing in the document attached)

Mr. / Mrs./ Ms.

Mobile Number Complete Postal Address

(as appearing in the document attached)

State:
Please affix recent colour photograph and sign across the photograph

PIN Email Id: Date of Birth(dd-mm-yy) PAN In case, you dont have PAN please fill
Form 60 (Annexure I)

Gender:

Identity Proof
(Self Attested)

(Submit any ONE of the valid documents and tick () against the document attached)

Drivers License

Voters ID Card

Passport

PAN

Address Proof
(Self Attested)

Gross Annual Income Upto Rs. 5,00,000 Rs.5,00,001 & above

Drivers License Voters ID Card Passport Ration Card Bank Statement/ Passbook Electricity /Mobile /Telephone Bill Occupation Private Sector Service Government / Public Sector Business Professional House Maker Student Retired Others

Declaration: I agree to abide by the terms, conditions, rules, regulations & other statutory requirement applicable to Prepaid Payment Instruments
issued by ZipCash Card Services Pvt. Ltd. (ZCSPL). I hereby declare that the particulars given herein are true, correct and complete to the best of my knowledge and belief, the documents submitted along with this application are genuine and I am not making this application for the purpose of contravention of any Act, Rules, Regulations or any statute or legislation or any Notifications, Directions issued by any governmental or statutory authority from time to time. I hereby undertake to promptly intimate ZCSPL, of any changes in the information provided herein above & agree and accept that ZCSPL is not liable or responsible for any losses, costs, damages arising out of any actions undertaken or activities performed by them on the basis of the information provided by me as also due to my not intimating /delay in intimating such changes. I hereby authorize ZCSPL to disclose, share, remit in any form, mode or manner, all/any of the information provided by me to ZCSPL for issuance of Prepaid Payment Instrument in which I may transact including all changes, updates to such information as & when provided by me. I hereby agree to provide any additional information/documentation that may be required by ZCSPL or its authorized agents, in connection with this form.

Signature of the Customer Date: Place:

Note: 1. The maximum limit for ZipCash is Rs.5000/2. Coupons are valid for 6 months from the date of purchase. 3. For any assistance or enquiries please contact 022-6672 0000. 4. By transacting you agree to the terms and conditions on www.zipcash.in
FOR OFFICE USE ONLY VERIFIED BY & DATE REFERENCE NO:

(as appearing in the document attached)

ANNEXURE - I FORM No. 60

(See second proviso to rule 114 B)

Form of declaration to be filled by a person who does not have a permanent account number and who enters into any transaction specified in rule 114B 1 Full Name & Address of the declarant :

2 3 4 5

Particulars of transaction Amount of transaction Are you assessed to tax? If yes, Details of the ward / Circle / Range where the last return of income was filed Reasons for having permanent account number

: : : :

Yes

No

Details of document being produced in support of address in column (1)

Verification
I, my knowledge and belief. Verified today, the Date: Place: SIGNATURE OF THE DECLARANT day of do hereby declare that what is stated above is true to the best of

Instructions: Documents which can be produced in support of the identity are: Passport Driving License Voters ID Certificate of identity signed by MP or MLA or Municipal Councilor or Gazetted Officer.

FOR OFFICE USE ONLY

VERIFIED BY & DATE

REFERENCE NO: