TICK YOUR CHOICE OF ICICI BANK CREDIT CARD* (Tick just one)

Mine Credit Card by ICICI Bank ICICI Bank Credit Card ICICI Bank Credit Card
Visa Visa

ICICI Bank Credit Card MakeMyTrip ICICI Bank MakeMyTrip ICICI Bank Platinum
Signature Credit Card Credit Card
Visa Visa

Manchester United Signature Credit Card Manchester United Platinum Credit Card ICICI Bank HPCL Credit Card
by ICICI Bank by ICICI Bank Visa
Visa
InterMiles ICICI Bank Credit Card InterMiles ICICI Bank Credit Card InterMiles ICICI Bank Credit Card
Visa

✔ ICICI Bank Platinum Chip Credit Card ICICI Bank HPCL Super Saver Credit Card Accelero ICICI Bank Credit Card
✔ Visa Visa

ICICI Bank Emeralde Credit Card

ABOUT YOURSELF

All fields marked with* are mandatory.

Prefix First Name Middle Name Last Name

Name
(Same as ID proof) Mr GAURAV KUMAR RAI
Name to be printed on Credit Card* GAURAV KUMAR RAI
(Maximum 19 characters, including spaces)

Date of Birth* 03/06/1995 Place of Birth* MADHYA PRADESH

Father Name* AJIT KUMAR RAI
Spouse Name*
Mother Name* KANTHI KUMARI
Gender* ✔ M- Male F- Female Other Marital Status* Married ✔ Unmarried Other
Citizenship* ✔ IN- Indian Other (ISO 3166 Country Code IN )
Residential Status* ✔ Resident Individual Non Resident Indian Foreign National Person of Indian Origin
Proof of Identity PAN Card BSHPR4807A
PROOF OF IDENTITY (Pol)* CURRENT / PERMANENT ADDRESS DETAILS

Address Type* ✔ Residential/Business Residential Business Registered Office Unspecified

Proof of Address* Passport Driving Licence ✔ UID (Aadhaar) Voter Identity Card

Current Residential Address*

FLAT NO 302 NH HOMES ROYAL VILLAS, RALLAGUDA ROAD
SHAMSHABAD
Landmark NEAR CSK PRESTAGE COUNTY City/District RANGAREDDY State/U.T code* TELANGANA
Pin* 501218 Country INDIA ISO 3166 Country Code* IN Tel. (Resi.) Mobile (In India)
7024519696
Permanent Residential Address*
FLAT NO 302, KAILASH ARCADE KHAMARIA
CHAMPANAGAR JABALPUR MADHYAPRADESH
Landmark TEMPLE City/District JABALPUR State/U.T code* MADHYA PRADESH
Pin* 482005 Country INDIA ISO 3166 Country Code* IN Tel. (Resi.) Mobile (In India)

E-mail ID (Personal)* [email protected]

Type of Residence Bungalow Row House Flat Others (Please Specify) Year(s) at current address 25
Residence Status* Owned Rented With parents Provided by Company With Relatives/Friends Others (Please Specify)

Family/Relative Reference 1 Name AJITH

Address

City* Pin*

STD code Tel.: Mobile 7002100699

Is your current residential address same as your permanent address? Yes No

 I hereby declare that I have reviewed and verified the current address details entered in the application form to be true, correct and updated and the application number
mentioned with respect to the application form has been generated by ICICI Bank post my review, verification and confirmation of the application details and I am also aware -
that in case of EKYC my permanent address would be updated as per Aadhaar
 ABOUT YOUR WORK

Academic Qualification* Graduate / Diploma Holder ✔ Professional

✔ ✔ Public Sector Professional Self-employed
B-Business X-Not Categorised
GMR AIR CARGO AND AEROSPACE ENGINEERING
Employer Details ✔ Public Ltd. Public Sector Multinational Others (Please specify)

✔ Retailing Agriculture Real Estate Others (Please specify)

Consultant Others (Please specify)

SUPERVISOR
Employee ID (mandatory if salaried) MR1348 No. of year(s) in current job* Total experience (No. of years)*

Net Annual Income* 350000 Gross Annual Income*

Office Address* PLOT NO 1 GMR AERO TECH

RGIA HYDERABADV SHAMSHABAD Landmark NEAR BPCL BUNK City/District HYDERABAD
Pin* 500108 State/U.T code* TELANGANA Country ISO 3166 Country Code* IN
STD code* 040 Tel.* 23102310 Ext* 040 Mobile (In India)

Office E-mail ID* (Mandatory if salaried) [email protected]

SUPPLEMENTARY CREDIT CARD APPLICATION (Liability of the Supplementary Credit Card will be on the Primary Cardholder)

Please complete this section to apply for Supplementary Card. Supplementary Card can be issued to family members (over 18 years of age) of the Primary Cardholder

Relationship

Prefix First Name Middle Name Last Name

Name
Please sign across
Please send colour Photograph(s) only. This would be
Date of Birth* Gender* Male Female Others retained by us for our records. Please do not use pins, tapes
or staples to affix your photograph.

Name as desired on Card*

(Maximum 19 characters, including spaces)

Current Residential Address*

Landmark City/District State/U.T code*

Pin* Country ISO 3166 Country Code* Tel. (Resi.) Mobile (In India)

Proof of Identity PAN Card

Please provide separate documents for proof of identity and proof of residential address. Only a valid passport will be accepted in both cases. At any given
time, a maximum of 3 supplementary cards will be issued to a primary Cardholder including any supplementary cards issued against any other ICICI Bank
Primary Credit Card. **As per the provisions of Reserve Bank of India Master Circular (RBI/2009-10/73; DBOD, AML, BC, No. 2/14, 01, 001/ 2009-10) on Know
Your Customer (KYC) norms dated July 01, 2009, it is mandatory for all banks to update the customer identification documents (including photographs). We
confirm that the information given above is true and correct. We understand that the Primary Cardholder will be liable for all the charges incurred with the
Primary Card and the Supplementary Card. We jointly and severally agree to be bound by the Rules and Regulations of use of the Credit Card, copy of which
we have received and understood. In particular, we confirm the usage in strict accordance with the Exchange Control Regulations of the Reserve Bank of India.
We understand that in the event of failure to do so, we are liable for action under the Foreign Exchange Regulation Act, 1973 and may be debarred from holding
the ICICI Bank Credit Card, either at the instance of ICICI Bank or the RBI. We authorise ICICI Bank to verify information in this application and to receive and
exchange information about us with other banks, agencies, companies for marketing and administrative purposes or for prevention of frauds, etc.

SUBSCRIPTION FOR CREDIT CARD VALUE ADDED SERVICES

Preferred mailing address* Residence ✔ Office (Please select only one)

I want to subscribe for* Statement by e-mail ✔ Mobile Alerts

Mobile No. 7024519696

E-mail ID [email protected]
Alternate E-mail ID
I understand that under the alert facility, ICICI Bank will enable me to receive customer alert messages with respect to events /transactions relating to my Credit Card or
informational/promotional mail that will be useful to me over my mobile phone or through e-mail. I agree to receive communication on my alternate e-mail ID in case
the alert messages with respect to any event/ transaction are not delivered to my preferred e-mail ID. (subject to information provided in the Application Form). I agree
to abide by the Terms and Conditions of ICICI Bank in this regard.

Auto Debit Facility ✔ I want to subscribe I don’t want to subscribe

I, do hereby unconditionally and irrevocably authorise ICICI Bank Ltd. to raise the debit of my regular Credit Card payments against my Savings/ Current Account number

771401500189 maintained with ICICI Bank Ltd. Branch, with an amount equivalent to the
✔ Minimum Amount Due Total Amount Due (please tick one of the boxes) as indicated in the Monthly Statement of charges on the due date.

Note: Auto Debit Facility is only available to Savings/Current Account holders of ICICI Bank Ltd. with Operating Instructions Single/Either or Survivor/Anyone or Survivor.
If the option of debiting the Minimum Amount Due or Total Amount Due is not clearly indicated in this Auto Debit application, ICICI Bank will activate the option of
Minimum Amount Due by default.
 OTHER INFORMATION
I am interested to know more about the service(s)/products(s) selected below and hereby provide the consent to ICICI Bank and/or any third party/parties who
is/are offering the below products to contact me for the same. I understand that this service(s)/product(s) is an offer from the third party/parties mentioned
below and that the particulars contained in this form shall be shared with any third party pursuant to ICICI Bank arrangement with the third party for offering
the said service(s)/product(s), as may be required or as ICICI Bank may deem fit.
Please tick from the below mentioned service(s)/product(s):

Card Protection Plan (CPP) offered by CPP Wallet Assist service offered by
Assistance Services Pvt. Ltd. One Assist Consumer Solutions Pvt. Ltd.

We have now digitised our Welcome Kits as part of the GoGreen initiative, an endeavour to reduce use of paper and make our contribution to this noble cause. If
you have applied for any of these products, your Credit Card welcome pack shall carry the welcome letter and the card plastic only: ICICI Bank Sapphiro, ICICI
Bank Rubyx, ICICI Bank Coral, ICICI Bank HPCL Coral, ICICI Bank Platinum Chip Credit Cards, Ferrari Credit Cards by ICICI Bank, Manchester United Credit
Cards by ICICI Bank and MakeMyTrip ICICI Bank Credit Cards.
The detailed membership guide, Terms & Conditions and Most Important Terms & Conditions (MITC) are available online in a PDF format. To download, please visit
www.icicibank.com/cc-ewelcomekits.
The physical copy of the membership guide, Terms and Conditions and MITC shall be made available by ICICI Bank upon request made by calling our Customer
Care.

Cross-sell Ref. No.: CRM ID:

Lead Generator EMP ID C75397 Lead Fulfiller EMP ID 485708

Application Ref. No. 7202003657063 307Logo

DMA Code: 0451399 Promo Code: AST Channel Code: Y9LF Branch SOL ID: 7754 Company Code:

IP and Coordinates 172.16.64.128 (,) Name as per NSDL (PAN)

I am an existing JetPrivilege member Yes No Membership number

Jet Privilege Membership Tier Blue Blue Plus Silver Gold Platinum

Application Type* ✔ New Update KYC Number

Application Type* Normal Simplified (for low risk customers) Small

DOCUMENT UPLOAD MATRIX

Photograph ✔

OVD (any one of the documents) Passport Voter’s Identity Card Driving License ✔ Aadhaar Card

Deemed OVD (any one of the document) Property or Municipal tax re ceipt Pension or family pension payment orders (PPOs)

Rental Agreement & latest utility bills

Utility bill which is not more tha n two months old

Electricity Bill Piped Gas Bill Telephone Bill Post-Paid Mobile Phone

Water Bill

Permanent government employees Photo ID Card

Revised -Gas Connection card not more than 2 months old

Original Letter from Govt. bodies certifying residential address

Quarters allotment letter issued by Govt.

Registered License agreements along with recent utility bills not older than two months
in name of landlord

Customer Consent One Pager ✔

 I/We declare that all the particulars and information given in the application form are at any time and only enhancements, if any, to the Credit Limit and/or the Cash Limit,
true, correct, complete and up to date in all respects and I/we have not withheld any shall be effected by ICICI Bank with the consent of the Cardholder.
information. I/We confirm that I/we have had no insolvency initiated against me/us nor  DECLARATION FOR INFORMATION SHARING I/We have no objection to ICICI Bank
have I/we ever been adjudicated insolvent. I/We have read the application form and Limited, its group companies, agents/representatives to provide me/us information on
brochures and am/are aware of all the terms/conditions of availing finance from ICICI various products, offers and services provided by ICICI Bank Limited/its group
Bank Limited. I/We authorise ICICI Bank Limited to make references and enquiries companies through any mode (including without limitation through telephone
related to information in this application which, ICICI Bank Limited considers necessary. calls/SMSs/e-mails) and authorise ICICI Bank Limited, its group companies,
I/We undertake to inform ICICI Bank Limited regarding change in my/our agents/representatives for the above purpose.
residence/employment and to provide any further information that ICICI Bank Limited
may require. Yes ✔ No (Please tick Yes or No, as acceptable)
 I/We understand that certain particulars given by me/us are required by the operational  I/We have no objection to ICICI Bank sharing my/our information with any parent,
guidelines governing banking companies. subsidiary, affiliates or associate of ICICI Bank, for the purposes of marketing and
offering various products and services of ICICI Bank or its group companies,
 I/We declare that I/we have read the application form and brochure and am/are subsidiaries, affiliates and/or associates.
agreeable to the terms/conditions of availing the Credit Card from ICICI Bank Limited.
Yes ✔ No (Please tick Yes or No, as acceptable)
 I/We further agree to the terms governing the issuance of a Supplementary Card as
specified in the Terms and Conditions governing the Credit Card. I/We have read and understood the Terms and Conditions to the ICICI Bank Customer
 I/We declare and undertake that the Credit Cards issued to me/us, if used overseas, shall  Manchester United want you to be first to know about New Signings, Competitions,
be utilised strictly in accordance with the relevant exchange control regulations issued Club News, Ticket Availability and occasional offers from official sponsors and partners.
and as amended by the Reserve Bank of India (RBI) from time to time. In the event I/we To stay updated, select Yes No
exceed my/our entitlements as per the exchange control guidelines of RBI, I/we  Internationally valid Card and all other Cards cannot be used on Internet or otherwise for
undertake to bring the same immediately to the notice of ICICI Bank Limited in writing. the purchase of prohibited items like lottery tickets, banned or proscribed magazines,
Further, I/we also agree and understand that if I/we am/are required to get my/our participation in sweepstakes, payment for callback services, remittance in any form
passport endorsed for any charges incurred by me/us as stipulated by RBI, the onus of towards overseas forex trading, margin calls to overseas exchanges/overseas
getting my/our passport endorsed shall lie entirely on me/us. In the event of any failure counterparty, trading in foreign exchange in domestic/overseas markets including
to comply with the prevailing exchange control guidelines issued by RBI to me/us, I/we binary option trading with commodities, stocks, indices, virtual currencies, bitcoin index
shall be liable for any action under the Foreign Exchange Management Act, 1999, as and forex etc. ICICI Bank does not deal in virtual currencies or provide services to any
amended and be debarred from the Credit Card facility either at ICICI Bank Limited person dealing in virtual currencies in any manner, such services including maintaining
instance or by RBI. accounts, registering, trading, settling, clearing, giving loans against virtual tokens,
 In the event of a Credit Card programme closure or at the time of renewal of Credit Card, accepting them as collateral, opening accounts of exchanges dealing with them and
ICICI Bank Limited at its sole discretion reserves the right to provide a card type that is transfer / receipt of money in accounts relating to purchase/ sale of virtual currencies.
different from the existing card type held by the Cardholder. The credit limits and cash  I/We declare that, in the event of change in address due to relocation or any other
limits on any Credit Card at any point in time are as per sole discretion of ICICI Bank reason, I would intimate the new address to the bank within 2 weeks of such a change.
Limited.
 I hereby give consent to ICICI Bank for linking my ICICI Bank Credit Card with my
 The card application shall continue to be valid for any replacement card provided at the existing ICICI Bank savings/current account, if any. I understand that this would enable
time of closure/renewal. me to access my ICICI Bank Credit Card account using the existing user ID provided to
 ICICI Bank Limited reserves the right to provide the applicant with a card type based on me under my ICICI Bank savings/current account, if any, through internet banking and
information available with ICICI Bank Limited assessment of the applicant’s credit rating. iMobile facility. I provide consent to and authorize ICICI Bank to use the KYC details
provided by me including but not limited to my Aadhaar card number for the aforesaid
 I/We authorise ICICI Bank to exchange, share or part with all the information relating to purpose. I further understand that I may delink my ICICI Bank savings/current account
me/us and repayment history to credit bureaus, agencies, statutory bodies, market from my ICICI Bank Credit Card by calling ICICI Bank Customer Care number available at
research agencies for conducting research as may be required and shall not hold ICICI www.icicibank.com.
Bank (or market research agencies) liable for use/sharing of this information.
 I confirm and authorise to a) Use my Aadhaar details to authenticate me from UIDAI b)
 I confirm that I am the sole account holder or I have the required mandate in case of joint Unique Identification Authority of India (UIDAI) to release my demographic details to
accounts to singly operate accounts. ICICI Bank through biometric authentication which ICICI Bank may use for KYC
 I/We understand that any change(s) in the Terms and Conditions will be communicated verification (identity/ address proof) for the purpose of Credit Card.
to me/us and will also be available to me/us on request.  I/We declare Except to the extent disclosed to ICICI Bank, no director or a relative/near
 JetPrivilege Membership I/We authorise ICICI Bank to exchange, share or part with all relation (as specified by RBI) of a director of a banking company (including ICICI Bank)
the information relating to me/us as contained in this application form and/or the details or a relative/near relation (as specified by RBI) of a senior officer of ICICI Bank (as
of the Jet Airways ICICI Bank Credit Card, if any to be issued to me with JetPrivilege specified by RBI) is: the applicant(s), or a partner of our concern, or a trustee, member,
Programme Partner and/or any other third party pursuant to ICICI Bank arrangement director, manager, employee of our concern, or of our subsidiary, or our holding
with Jet Airways and/or any other third party in relation to the Jet Airways ICICI Bank company, or a guarantor on my/our behalf, or holds substantial interest in our concern
Credit Card, as may be required or as ICICI Bank may deem fit and I/we shall not hold or my/our subsidiary or holding company.
ICICI Bank liable for use/sharing of this information. Note: If you are not a JetPrivilege  You can change your preferences or unsubscribe any time by contacting Manchester
Member, you will be automatically enrolled. Also, if we do not receive your existing JP United (“MU”) at the address below. By signing up, you agree to Group using your
membership number in this application form, a new JP membership number will be personal data in accordance with their Privacy Policy. MU uses your data to personalise
allotted to you and linked to your Credit Card. Please note that by applying for the Jet and improve your experience on their digital platforms, provide products and services
Airways ICICI Bank Credit Card you are consenting to the Terms and Conditions of you request from them, and carry out profiling and market research. Please read Privacy
membership of the Jet Airways JetPrivilege programme. Policy (which includes an updated list of MU Group companies & MU official sponsors
These can be fund at www.jetairways.com and partners) at https://www.manutd.com/ or for a copy write to the MU Data Protection
 I confirm to have read and understood the schedule of charges, and agree to be levied Officer at Manchester United Football Club Limited, Sir Matt Busby Way, Old Trafford,
the applicable fees and charges for the Credit Card chosen by me Manchester, M16 0RA.

 I have not paid any cash or cheque for the Credit Card annual fee at the time of  You hereby authorise ICICI Bank Ltd (“ICICI Bank”) to share your data or information
application associated with your MakeMyTrip ICICI Bank Credit Card ("Card application”) (i) E-mail
address; (ii) Mobile number; (iii) 16-digit Credit Card number in encrypted form; (iv)
 Issuance of the said Credit Card is at the sole discretion of ICICI Bank Ltd. The credit Card variant availed (Platinum/Signature); (v) Credit Card expiry date in encrypted form;
limits on the Credit Card account will be fixed by the bank based on my income (vi) Credit Card account no. with MakeMyTrip (India) Private Limited and its affiliates
documents. (“MMT”) to update its records and provide you services, rewards & benefits with respect
 For cash withdrawals, interest will be charged from the day of the transaction and no to the Card. If you wish to opt out of such sharing of your data by ICICI Bank with MMT,
free credit period will be provided you may cancel your Card at any point of time by calling our Customer Care.
 Processing time: A minimum of 10 days.  You hereby agree that in case the e-mail address provided by you in the Card
application does not have a corresponding MMT account, MMT shall provide you with
 I am aware that as part of the bank's GoGreen initiative, the Credit Card Welcome Kit for
services, rewards & benefits associated with the Card on your MMT account
ICICI Bank Credit Cards has been digitised. The PDF copy of the membership guide,
corresponding to your mobile number.
Terms and Conditions and Most Important Terms and Conditions (MITC) is available for
download at www.icicibank.com/cc-ewelcomekits. A physical copy of the same shall be Further in case you do not have an MMT account corresponding to either your e-mail
made available by the bank upon request made by calling ICICI Bank's Customer Care. address or your mobile number, you agree and acknowledge that MMT shall create a
new MMT account on your behalf with your e-mail address and/or mobile number, as
 CREDIT LIMIT DECLARATION The Cardholder shall be entitled to apply for a
the case may be, provided under the Card application. MMT shall update you with
review/enhancement/reduction of the Credit Limit and/or Cash Limit (if provided by
details of the new MMT account and steps to access the new MMT account by way of
ICICI Bank), upon completion of 12 months of his/her membership. Alterations upon
an SMS and/or e-mail.
such review, if any, of the Credit Limit and/or Cash Limit will be at the sole discretion of
ICICI Bank. ICICI Bank shall at its sole discretion be entitled to review (including  For more information regarding information disclosures, please check ICICI Bank Card
enhancement or reduction) of the Credit Limit and/or Cash Limit assigned on the Card Terms & Conditions.

• I confirm that I have gone through all the Terms and Conditions, Most Important Terms & Conditions and Important Credit Card Declaration and hereby
agree to abide by the same.

• I hereby consent to receiving information from Central KYC Registry through SMS/e-mail on the above registered number/e-mail ID

28/01/2022 RANGAREDDY