MobiKwik Wallet KYC FormMobiKwik Wallet KYC Form

Wallet Details

Phone number linked with Wallet

1

Identity Details (as per ID Proof)2

Address Details (as per Address Proof)3

Declaration4

Seal/Stamp of Verifying Agency

Documents verified against originals

Self-attest verifiedPhotos Collected

Please a�x recent passport sized photo

graph.

Cross sign the photograph

For O�ce Use Only5

(Bank Statement/Utility Bills should not be more than 2 months old)

Flat No. / Plot No. / House No. / Building / Area

Address Proof Submitted

Aadhar Card

Utility Bills

Bank Statement

Pension Payment

Driving License

NREGA Job Card

Voter ID

Municipal Tax Receipt

Passport

City/District

State PIN Code

Email ID linked with Wallet

I hereby declare that the above furnished details are true to the best of my knowledge. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

SignaturePlace Date

Agency Name

Agent Name

Gender Male Female

ID Proof Submitted

PAN Card Aadhar Card Driving License Passport

Voter ID NREGA Job Card Government Issued ID Proof

D D M M Y Y Y Y

Please fill in BLOCK letters. One Mobikwik Systems Private Limited

(recommended)

(should have photograph)

Name

Date of Birth