Doing Business As (Name) : Permanent Account Number : Place of Incorporation: Registered Address : Fax :
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1 The form should be signed after all details are completely filled. oing Business As (Name) M M Permanent Account Number Place of Incorporation Registered Address City State Country PIN Fax Mobile City Country State Correspondence Address c Please tick, if correspondence address should be maintained same as the Registered address PIN Fax Mobile Are your Primary locations/trade areas, customer/supplier domiciled in any of the below mentioned list of Sanctioned Countries? List of Sanctioned Countries Syria Iran Sudan Cuba North Korea Cremia Region (Please tick as applicable) M M I/We, do hereby declare that is stated above is true to the best of my/our knowledge and belief. First Signatory Second Signatory 1 of 6 Third Signatory es No
2 Account Operation Instructions As per Board Resolution Form 60 c es (If yes, please fill & attach the Form 60 separately) Mandatory if PAN Number not mentioned Nomination c es (If yes, please fill & attach the Nomination form separately) c es (If yes, physical copy of the account statement will be sent only annually) c es (If yes, please fill & attach the ebit card application form) Signature (Applicable only for sole proprietor) Channel Facilities Statement on For Internet Banking kindly approach the branch separately for registration formalities. Existing Banking Relationship c es Accounts with other Banks c es If es, Account No. & type Branch & Address Bank c I/We declare that we do not enjoy credit facilities with any bank/banks c I/We declare that we enjoy following credit facilities with other bank/banks Branch & Address Bank Account Type Facility Amount 10 (If yes, please tick below) ten A E A E z Signature Signature 2 of 6 Account with Citibank
3 etails of Signatories (1) Mr./Ms./Mrs./Mx. Address Paste Color Photograph State M M ate of Birth Country ender c Male c Female c Third ender Aadhaar Nationality Occupation / esignation (2) Mr./Ms./Mrs./Mx. Address State M M ate of Birth Paste Color Photograph Country ender c Male c Female c Third ender Aadhaar Nationality Occupation / esignation (3) Mr./Ms./Mrs./Mx. Address Paste Color Photograph State M M ate of Birth Country ender c Male c Female c Third ender Aadhaar Nationality Occupation / esignation Signature 3 of 6
4 I/We hereby authorize Mr./Ms., Officer of Citibank N.A. India to assist me in completing my application form and related documents, prior to my signing the Application Form. It is my responsibility to read, understand and satisfy myself that the contents mentioned on the Application form are filled as per my instructions as to the correctness and completeness in all respects, prior to signing and it is binding on me/us. By submitting Aadhaar number to Citi, I/we hereby authorize Citi to collect, store, use, authenticate your Aadhaar number and demographic details (Information) against UIAI database by itself or via Experian Services India Pvt Ltd, an Authentication User Agency duly licensed by UIAI before updating your account and also share Information with its various departments, affiliates and service providers for any account to which you are signatory(-ies) or an account holder or are availing banking services from the Bank currently or may do so in future. Citibank will use the Aadhaar number to offer banking and transaction services to me/us, as may be applicable. Citibank may use your demographic and biometric/otp (One Time Password) (or any similar authentication mechanism) information for the purpose of Aadhaar based authentication/ e-kc. Name First Signatory with Stamp Name Second Signatory with Stamp Name Third Signatory with Stamp Note As per RBI's latest "Know our Customer" circular, we request you to kindly furnish identification proofs for all signatories and the firm/company. The proofs required are photo identification, signature proof and address proof. ou can check with the Relationship Manager on the acceptable documents for identification. This exercise enables us to meet the objectives of the Know our Customer programme and further enables us to service you better. Citigroup Inc., including its branches, subsidiaries and managed affiliates, including Citibank, N.A., (collectively, Citi ) is committed to conducting business in compliance with all applicable U.S. laws and regulations, as well as those of each jurisdiction where Citi has operations. Among these laws and regulations, Citi is required to follow applicable sanctions laws and regulations in each jurisdiction where it conducts business, including, without limitation, applicable sanctions programs administered by the U.S. epartment of the Treasury s Office of Foreign Assets Control ( OFAC ), competent authorities of the European Union (E.U.) Member States and competent authorities of United Nations (U.N.) Member States that implement U.N. Sanctions (collectively local sanctions ). Local Sanctions programs are usually implemented through measures such as the blocking or freezing of assets of, and the imposition of certain trade, commercial and financial restrictions on, designated sanctions targets. Under this local sanctions compliance, Citi has the right to refuse processing of any specific document / transaction, if the trade is done with / facilitated by any entity facing sanctions under U.S, U.N., E.U. and/or Indian Laws. Citi Priority CitiBusiness OneWorld (MNC Subs) CitiBusiness Leap (Startup) Sourcing Channel Referral I 4 of 6 I/We hereby understand that Citi may ask for our business name, street address, tax identification number or other government issued identification number, as applicable to help prevent money laundering and terrorist financing, the law of many jurisdictions, as well as Citi policy,require Citi to obtain, verify and record information that identifies each business entity that opens an account or establishes a relationship
5 Cheque Pickup Charges Free Free ` 500 per month Nil + ST as applicable, in accordance with ST provisions as per overnment of india latest notifications on Foreign Currency Conversion for FC sales/purchase. ST Mumbai, elhi, Noida, urgaon, Faridabad, Kolkata, Chennai, Bangalore, Pune, Hyderabad, Ahmedabad and Thane Aurangabad, Chandigarh, Cochin, Coimbatore, Jaipur, Lucknow, Nagpur, Nashik, Baroda and Surat For CitiBusiness Leap accounts, no charges for non-maintenance of Minimum Average Monthly Relationship Value, for 12 months from the date of account opening 2018 Citigroup Inc. Citi, Citibank and Arc esign are registered service marks of Citigroup Inc. or its affiliates used and registered throughout the world. Signatory with Stamp 5 of 6 CitiBusiness Schedule of Charges - Applicable to all current accounts
6 eclarations (as applicable for your type of entity) Sole Proprietor Name Place Signature ate Firm Seal Partnership Name of the Partner Name of the Partner Name of the Partner First Signatory Second Signatory Third Signatory (Note each partner has to sign in his/her individual capacity without affixing any seal/rubber stamp) Place Firm Seal ate Coparceners coparcener coparcener Name Name Name First Signatory Second Signatory Third Signatory Karta Seal & Sign Place 6 of 6 ate
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