Name of Applicant (As appearing in supporting Identification document)

First
Middle
Last
M F
Date of Birth (dd/mm/yyyy)
Shop Name
Shop Address
Mohalla /Village
Tahsil / Taluka
City /Town
Pin Code
State
STD code
Telephone No.
Mobile No.
Alternate Mobile
Email ID:
Address
Know Your Customer (KYC) Application Form
For CSP Appointment
Permanent Account No. (PAN)
Registration Details
Gender
PAY POINT INDIA NETWORK PVT LTD
Please fill this form in ENGLISH and in BLOCK LETTERS (All information as applicable in the form
below is mandatory). This information is sought under the CSP's KYC guidelines of Pay Point
India Network Pvt. Ltd. who is a national business correspondent (BC) of State Bank of India.
(BC Code: 1A660000)
Please affix a recent
color photographs
and sign across the
photograph

Mohalla /Village
Tahsil / Taluka
City /Town
Pin Code
State
STD code
Telephone No.
Urban
Branch IFSCode
District Coordinator Name
How do you know about Pay Point India ?
Reg. Fee (Non Refundable)
Name of Village_________________________
Population Category
Linked Branch Name (SBI Branch)
Rs
Computer Internet
Printer Inverter
Residence Address
District Coordinator Others
Infrastructure
Semi-Urban Metro
Rural
Sr. No.
Place:
Date
(DD/MM/YYYY)
CSP Code (For official use only)
The documents submitted along with this form should not be more than six months old as on the date of
submission of this form.
Documents Required (To be attested by First Class Magistrate / Gazetted Officer / Notary Public):
Documents
Mandatory
Copy of any of the following documents
1. Passport
Copy of Permanent Account
Number Card (PAN Card)
Proof
Photo Identity Proof 2
3 Address Proof
2. Voter's Identity Card
3. Driving License
Copy of any of the following documents
1. Latest Bank Account Statement issued by
Nationalized / Schedule Bank
3. Ration Card
NOTE: Please send this form duly filled-up and signed to:
Pay Point India Network Pvt. Ltd.,
2nd Floor, Shushil Apartment, Kamla Nehru Cross Road No.1, Kandivali (W), Mumbai - 400 067, Maharashtra.
DECLARATION
I agree to abide by the terms, conditions, rules, regulations and other statutory requirements applicable to the
respective business application. 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
providing this form in 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
inform Pay Point India Network Pvt. Ltd., 2nd Floor, Shushil Apartment, Kamla Nehru Cross Road No.1, Kandivali (W),
Mumbai - 400 067, Maharashtra of any changes in the information provided herein above and agree and accept that
Pay Point India Network Pvt. Ltd., is not liable or responsible for any losses, cost, 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 Pay Point India Network Pvt. Ltd., to disclose, share,
remit in any form, mode or manner, all / any of the information provided by me to Pay Point India Network Pvt. Ltd.,
for issuance of business ID in which I may transact including all changes, update to such information as and when
provided by me. I hereby agree to provide any additional information / documentation that may be required by Pay
Point India Network Pvt. Ltd., or its authorized persons, in connection with this Form.
________________________________ _____________________________________
Signature of Applicant
2. Electricity Bill (not more than 3 months old)
4. AADHAR Card
1