empanelment form for aadhaar enabled … gram digital forms final.pdf · aeps authority &...

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EMPANELMENT FORM FORAADHAAR ENABLED PAYMENT SYSTEM (AEPS) AGENT

For Office Internal Use

Form Recd Date -

AEPS Prov. ID -

AEPS ID Date -

AEPS Code -

AEPS Approv. Date -

First Name -

Middle Name -

Last Name -

Current Address -

PIN-

Are you staying on rent?

Email Id-

Permanent Address -

(Business Address)-

Have you worked with any Money Transfer companies or as

Agent / Channel Partners for any organization ?

Mobile No.-

Landline No.-

Yes

Yes

No

No

Birth Date -

Gender -

Edu. Qualification -

Father's First Name -

Father's Mid. Name -

Father's Last Name -

D D M M Y Y Y Y / /

PERSONAL DETAILS

COMMUNICATION DETAILS

WORK EXPERIENCE DETAILS

(Please fill in BLOCK LETTERS)

(Please write name & birth date exactly as per attached ID Proof)

(Please write Current Address exactly as per attached Address Proof)

(Please Tick)

(Please Tick)

(Enter 6 Digit PIN Code)

( S T D C o d e ) ( L a n d l i n e N u m b e r )

Male Female

+ 9 1

+ 9 1

Please note - Current Address & Permanent Address Should not be same.

(P.T.O.)

Please affix

Recent Color

Passport Size

Photograph.

1


Employer Name -

Address -

Employer Name -

Address -

Employer Name -

Address -

Contact Number -

Contact Number -

Contact Number -

Worked From -

Worked From -

Worked From -

to

to

to

AEPS Authority & E-Gram Digital has the right to call for any information to verify your work experience

with above mentioned employers & organizations.


DETAIL # 1

DETAIL # 2

DETAIL # 3

Please enter previous work experience. Start with Current Employer / Business.

+ 9 1

+ 9 1

+ 9 1

(P.T.O.)

(Minimum 1 Experience detail is required.)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)

2



ID Proof

Address Proof

Reference Name -

Address -

Reference Name -

Address -

ID Proof Number -

ID Proof Number -

Contact Number -

Contact Number -

AEPS Authority & E-Gram Digital will cross check these references as per the Bank's & RBI's

guidelines for Empanelment.

KYC PROOFS ATTACHED

REFERENCES

REF # 1

REF # 2

+ 9 1

+ 9 1

(P.T.O.)

(Please Tick)

(Please Tick)

PAN Card is Mandatory. One more ID Proof is

required.

PAN Card*

Aadhaar Card

Bank Passbook with Photo

College ID Card issued in last 2 years

Driving License

Aadhaar Card

Ration Card

Consumer Gas Connection with Bill

Driving License

Passport

Bank Passbook (Max. 3 months old)

Post Office Savings Pass book

Voters ID Card with Valid DOB

Passport

Ration Card with Photograph


proof

X and XII marksheet with photo

Rent Agreement with Utility Bill

Sales Deed

Service Tax Registration Certificate

Shop Act License

Electricity Bill (max. 3 months old)

Telephone Bill (max. 3 months old)

Mobile Bill (max. 3 months old)

(Please enter ID proof which matches Personal Details of Applicant)

(Please enter Address proof which matches Current Address Details of Applicant)

( Both References are compulsory. Don’t give references of Relatives.)

3



DECLARATION BY APPLICANT

FOR INTERNAL OFFICE USE ONLY

I hereby understand and agree that -

the details submitted by me for empanelment is true & correct and belongs to me,

I have understood the terms of AEPS Business and agree to comply with Bank's,

Company's and RBI's guidelines from time-to-time,

I will maintain the required details for each transaction processed by me on behalf of

customer,

I will not misuse Company's or Bank's systems for unlawful transactions,

I will abide by the terms of agreement & service for which I am being empanelled.

My application for empanelment will be rejected in case documents, references,

experiences etc is found to be improper, incorrect or not as per RBI's, Company's

or NPCI's guidelines for empanelment.

I authorize E-Gram Digital, Provider and Bank to verify the details mentioned above

and such other details as they may deem fit in connection with my empanelment.

I confirm that I am not associated with any company providing AEPS Facility or such

other Aadhaar Enabled Services or I am willing to resign from any such company

for the purpose of onboarding with E-Gram Digital.

KYC Verification -

Sys. Logged -

Sys. Approval -

AEPS Code -

Task Date Official's Sign Official's Name

Important Notes -

1) Please submit self-certified (self-attested) copies of ID Proof & Address Proof.

2) Submit scan of form and ID/Address proof at [email protected]

3) Please scan in jpeg format at minimum 600dpi with image size below 500kb.

4) Please email the scanned passport size photo (600dpi & below 500kb) also.

Place -

Date - Signature with Stamp

4



EMPANELMENT FORM FORICICI BANK - BUSINESS CORROSPONDENT AGENT

For Office Internal Use

Form Recd Date -

CV Ref. ID -

CV Ref. ID Date -

CV ID Generated -

CV ID Appr. Date -

First Name -

Middle Name -

Last Name -

Current Address -

PIN-

Are you staying on rent?

Email Id-

Permanent Address -

(Business Address)-

Have you worked with ICICI Bank, ICICI group of companies or

ICICI Channel Partners / any other organization ?

Mobile No.-

Landline No.-

Yes

Yes

No

No

Birth Date -

Gender -

Edu. Qualification -

Father's First Name -

Father's Mid. Name -

Father's Last Name -

D D M M Y Y Y Y / /

PERSONAL DETAILS

COMMUNICATION DETAILS


(Please fill in BLOCK LETTERS)

(Please write name & birth date exactly as per attached ID Proof)

(Please write Current Address exactly as per attached Address Proof)

(Please Tick)

(Please Tick)

(Enter 6 Digit PIN Code)

( S T D C o d e ) ( L a n d l i n e N u m b e r )

Male Female

+ 9 1

+ 9 1

Please note - Current Address & Permanent Address Should not be same.

(P.T.O.)

Please affix

Recent Color

Passport Size

Photograph.

1


Employer Name -

Address -

Employer Name -

Address -

Employer Name -

Address -

Contact Number -

Contact Number -

Contact Number -

Worked From -

Worked From -

Worked From -

to

to

to

ICICI Bank & LN Impex International Pvt Ltd has the right to call for any information to verify your work

experience with above mentioned employers & organizations.


DETAIL # 1

DETAIL # 2

DETAIL # 3

Please enter previous work experience. Start with Current Employer / Business.

+ 9 1

+ 9 1

+ 9 1

(P.T.O.)

(Minimum 1 Experience detail is required.)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)

(Month) (Year)


2


ID Proof

Address Proof

Reference Name -

Address -

Reference Name -

Address -

ID Proof Number -

ID Proof Number -

Contact Number -

Contact Number -

ICICI Bank & LN Impex International Pvt Ltd will crosscheck these references as per the Bank's & RBI's

guidelines for Empanelment.

KYC PROOFS ATTACHED

REFERENCES

REF # 1

REF # 2

+ 9 1

+ 9 1

(P.T.O.)

(Please Tick)

(Please Tick)

PAN Card is Mandatory. One more ID Proof is

required.

PAN Card*

Aadhaar Card

Bank Passbook with Photo

College ID Card issued in last 2 years

Driving License

Aadhaar Card

Ration Card

Consumer Gas Connection with Bill

Driving License

Passport

Bank Passbook (Max. 3 months old)

Post Office Savings Pass book


Passport

Ration Card with Photograph


proof

X and XII marksheet with photo

Rent Agreement with Utility Bill

Sales Deed

Service Tax Registration Certificate

Shop Act License

Electricity Bill (max. 3 months old)

Telephone Bill (max. 3 months old)

Mobile Bill (max. 3 months old)

(Please enter ID proof which matches Personal Details of Applicant)

(Please enter Address proof which matches Current Address Details of Applicant)

( Both References are compulsory. Don’t give references of Relatives.)


3


DECLARATION BY APPLICANT

FOR INTERNAL OFFICE USE ONLY

I hereby understand and agree that -

details submitted by me for empanelment is true & correct and belongs to me,

I have understood the terms of BC Business and agree to comply with Bank's,

Company's, Provider's and RBI's guidelines from time-to-time,

I will maintain the required details for each transaction processed by me on behalf of

customer,

I will not misuse Company's, Provider's or Bank's systems for unlawful transactions,

I will abide by the terms of agreement & service for which I am being empanelled.

My application for empanelment will be rejected in case documents, references,

experiences etc is found to be improper, incorrect or not as per ICICI Bank, Provider,

Company's or RBI's guidelines for empanelment.

I authorize LN Impex International Pvt Ltd, Provider & Bank to verify the details

mentioned here and such other details as they may deem fit in connection with my

empanelment.

I confirm that I am not associated with any company providing money transfer or

such BC Business Services or I am willing to resign from any such company for the

purpose of onboarding with LN Impex International Pvt Ltd.

KYC Verification -

Sys. Logged -

Sys. Approval -

CV ID -

Task Date Official's Sign Official's Name

Important Notes -

1) Please submit self-certified (self-attested) copies of ID Proof & Address Proof.

2) Submit scan of form and ID/Address proof at [email protected]

3) Please scan in jpeg format at minimum 600dpi with image size below 500kb.

4) Please email the scanned passport size photo (600dpi & below 500kb) also.

Place -

Date - Signature with Stamp


4

REGISTRATION FORM FOR E GRAM DIGITAL KENDRAREGISTRATION FORM FOR E GRAM DIGITAL KENDRA

Declaration:

I/We ________________________________ hereby declared that all the statements made by me in this application form are true and complete to the best of my knowledge.

Applicant’s signature (with Seal) ____________________________

Authorized signatory

(E‐Gram Digital)

Name : ____________________________

Father’s Name: _____________________________

Mobile : __________________________________

Outlet Name & Address : ______________________________________________________________________

___________________________________________________________________________________________

Address : _______________________________________

________________________________________

Declarations

Yours faithfully,

Applicant’s Signature

Name:____________________

Name:__________________

Date: _____________________(dd / mm / yyyy)

Place: _____________________

Office: E‐57, Ground Floor, sector‐03, Noida, UP‐201301Tollfree: 1800 419 3004 Email: [email protected]

www.egramdigital.co.in

LNIMPEX INTERNATIONAL PRIVATE LIMITED

I /We request you to appoint me/us to act as a Business Facilitator/ Business Correspondent / Retailer / Permanent

Enrolment Centre for the period of one year. Hereby submitting following declarations as an applicant of E‐Gram Digital

(A unit of LNIMPEX INTERNATIONAL PVT. LTD.).

I / We have not been found / pronounced to be of unsound mind by any competent authority and declared/adjudicated as insolvent by any

competent court and not found guilty of any criminal offence by any court of competent jurisdic�on.

I/We have not been found guilty of or to have knowingly par�cipated in or connived at any fraud, dishonesty or misrepresenta�on against a

banker or an insured in the course of any judicial proceeding rela�ng to any bank or in the course of an inves�ga�on of the affairs of a Banker.

I/We have not violated the code of conduct specified of any bank or declared a wilful defaulter by any bank or financial ins�tu�on. I/We

promise not to share the customer details with others and use only for the purpose of canvassing business of The LNIMPEX Interna�onal Pvt Ltd.

The LNIMPEX Interna�onal Pvt Ltd Retailer/Operator/PEC scheme has been read by me and I/We accept the same as binding upon me.

I/We hereby declare that all the informa�on provided is correct to the best of my/our knowledge and belief.

The fees/amount which I/We have paid is Non‐Refundable deposits or not adjustable under any circumstances in future.

If any other services will be Introduce/Add in future and Retailer wants to avail those services I/We will have to pay charges.

I/ We understand that my applica�on is liable to be rejected if it does not sa�sfy internal verifica�on of E‐Gram Digital as per the government

norms. I will cooperate with E‐Gram Digital official during the documenta�on process for allotment of authorized code/access to the services.

I/We agree to enter into this MOU with LNIMPEX Interna�onal Pvt. Ltd. (E‐Gram Digital) and execute the required documents at my / our cost in

the event of selec�on for appointment as E‐Gram Digital Business Facilitator/ Business Correspondent / Retailer / Permanent Enrolment Centre.

I/We undertake to complete all the formali�es required by the E‐Gram Digital within 7 days from the date of appointment and in case I/We fail to

do so, I/We agree that E‐Gram Digital shall have the right to cancel the appointment and forfeit the applica�on money.

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

IX.

X.

RT

Left hand thumb impression (Applicant)

Please affix

Recent Colour

Passport Size

Photograph

with

Cross Signature


empanelment form for aadhaar enabled … gram digital forms final.pdf · aeps authority &...

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