Loan Application Form (Individual)
Please fill in all the required details in BLOCK LETTERS. Tick ✓ boxes as applicable. All Fields Mandatory
✓ Personal Loan Co-Applicant
Please paste
Application Form No. PL00001298964 passport-size
photograph here
Requested Loan Amount 1 5 0 0 0 0 0 Tenure in Months 4 8
with signature
Type of Loan across
New Top-Up
For office use only
Application Type* New Update
KYC Number
Account Type* Normal Simplified (for low risk customers) Small
Demographic Details
Personal Detail Applicant Co-Applicant/ Guarantor
M r . P A R A M A
Name* N A N D
M r . K h i v r a j
Father's/ Spouse Name* S i n g h
M r s . M u n s i
Mother Name* D e v i
Date of Birth* 2 0 0 9 1 9 6 9
Gender* ✓ Male Female Male Female
Marital Status* Single ✓ Married Single Married
Citizenship* ✓ Indian Other ISO 3166 Country Code Indian Other ISO 3166 Country Code
✓ Resident Individual Non Resident Indian Resident Individual Non Resident Indian
Residential status* Foreign National Person of Indian Origin Foreign National Person of Indian Origin
✓ Service Private Sector Public Sector Service Private Sector Public Sector
Government Sector Government Sector
Others Professional Self Employed Others Professional Self Employed
Retired House Wife Student Retired House Wife Student
Occupation Type* Business Not Catagorised Business Not Catagorised
PAN* A R N P N 1 8 9 7 N
Qualification* G r a d u a t e
Relation with applicant
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Address
A a l i y a w a s h r o a d b h
a g w a n p u r a r i y a n b a
r i n a g a u r r a j a s t h
a n
District N a g a u r District
Pin/Post Code 3 4 1 5 1 3 Pin/Post Code
Current Address* State/U.T Code ISO 3166 Country Code State/U.T Code ISO 3166 Country Code
No. of years at current address 4 0 1 0
No. of years in current city 4 0 1 0
Current Residence* ✓ Self Owned Rented Other (Please specify) Self Owned Rented Other (Please specify)
Correspondence / Local address ✓ Same as Current/Permanent/Overseas Address details (In case of Same as Current/Permanent/Overseas Address details (In case of
details multiple correspondence / local addresses, please fill 'Annexure Al') multiple correspondence / local addresses, please fill 'Annexure Al')
A a l i y a w a s h r o a d b h
a g w a n p u r a r i y a n b a
r i n a g a u r r a j a s t h
a n
District N a g a u r District
Pin/Post Code 3 4 1 5 1 3 Pin/Post Code
State/U.T Code ISO 3166 Country Code State/U.T Code ISO 3166 Country Code
Preferred Mailing Address ✔ Current Office Permanent (Pls specify the reason for this selection)
Employment Detail Applicant Co-Applicant/ Guarantor
Occupation ✓ Salaried Self Employed Professional Salaried Self Employed Professional
Designation
Company/ Business Name* S T A T E G O V E R N M E N T
9 5 0 0 4 : S t a f f e d u c a t
Industry Type i o n l o a n s
Business Type Trader Manufacturer ✓ Service Trader Manufacturer ✓ Service
a y u r v e d i c a u s h a d h
a l a y D a s a w a s n a g a u
r S h y a l a w a s
Office Address* Pin 3 4 1 5 1 3 Pin
I n d i v i d u a l
Public Sector Pvt. Ltd. Partnership Proprietor Public Sector Pvt. Ltd. Partnership Proprietor
Business Constitution Public Ltd. Central Govt. ✓ State Govt. Public Ltd. Central Govt. State Govt.
Off. Ph. with STD Code
Extn. No.
c h o u h a n k r i s h a n k u m a
Official Email ID r 3 8 @ g m a i l . c o m
Total yrs in present occupation 3 2 0 2 years years
Total Work Experience 3 5 0 1 years years
Total Monthly Income 6 2 0 0 0 . 0
Other Income 0 . 0
Total 6 2 0 0 0 . 0
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Contact Details
Tel. (Off)
Tel. (Res)
FAX
Mobile* 9 8 8 7 9 7 6 0 9 8
c h o u h a n k r i s h a n k u m a
Email ID* r 3 8 @ g m a i l . c o m
Proof of Identity (Pol)*
PAN No. A R N P N 1 8 9 7 N Aadhar No.
GST No. Voters ID
Passport No. if passport, passport expiry date.
Driving License if DL, DL expiry date
Others (Pls Specify)
NREGA Job Card (any document notified by the central government)
Simplified Measures Account - Document Type code Identification Number
Proof of Address (PoA)*
Address Type* ✓ Residential/ Business Residential Business Registered Office Unspecified
Proof of Address* Passport Driving Licence ✓ UID (Aadhaar) Voter Identity Card NREGA Job Card Others (Pls Specify)
Simplified Measures Account - Document Type code
Detail of Related Person (In case of additional related persons, please fill 'Annexure B1')
Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available)
Related Person Type Guardian of Minor Assignee Authorized Representative
Name
Proof of Identity (Pol)*
PAN No. Aadhar No.
Voters ID
Passport No. if passport, passport expiry date.
Driving License if DL, DL expiry date
Others (Pls Specify)
NREGA Job Card (any document notified by the central government)
Simplified Measures Account - Document Type code Identification Number
Remarks (If any)
o k
Preferred Mailing Address Current Office Permanent (Pls specify the reason for this selection)
Existing Loans
Commencement Current
Loan/Facility Financer'sName Account No. Loan Amount Tenure Months EMI/Interest
Date Outstanding
Bank Details
Current/Savings/OD (If OD
Sr. No. Name of Account Holder Name of Bank Branch Account No. Banking Since
Please Specify Limit)
1
2
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Insurance Declaration
I/We hereby declare that I/We would like to opt for insurance plan offered by insurance company in association with ABCL I/We have carefully read and understood the contents of the brochure. I/We
have understood that the Loan/Facility amount sanctioned by ABCL is unconditional to my/our opting for the Insurance & undertake to pay the requisite premium at the time of disbursement of the loan.
I confirm that I am voluntarily participating in this program and am aware that the loan is available without the insurance as well.
Acknowledgement Application Form No. _________________________
Dear Sir/Madam,
This is to acknowledge that ABCL has received your application form for _________________________ of Rs _________________________ ABCL shall communicate its decision on your application
within 15 working days. This is subject to submission of all documents and conforming to internal guidelines of ABCL. Terms and Conditions are also available on our website :
www.adityabirlacapital.com
Business Development Manager: ______________________ Channel Name: _______________________ Contact No: _______________________
Date: _______________________ Email ID: ______________________________________________ Signature: _______________________
Reference 1 Reference 2
Name K a m a l S i n g h Name D i p e s h K u m a r
Relationship F r i e n d Relationship R e l a t i v e
If Personal Guarantor Yes No If Personal Guarantor Yes No
Current Address n a g a u r Current Address n a g a u r
Landmark n a g a u r Landmark n a g a u r
City M E R T A City M E R T A
State R A J A S T H A N Pin 3 4 1 5 1 3 State R A J A S T H A N Pin 3 4 1 5 1 3
Landline Landline
Mobile 8 9 3 2 1 4 5 6 9 8 Mobile 7 7 2 3 6 9 8 5 2 0
Declaration
1. I/We hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I under take to inform you of any changes therein, immediately. 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. 2. I /We confirm that no insolvency proceedings or suits for recovery of outstanding dues or monies
whatsoever and/ or any criminal proceedings have been initiated and /or are pending against me/ us and that I/We have never been adjudicated insolvent by any court or other authority. 3. No action nor other steps have
been taken or legal proceedings started by or against me/us in any court or law/other authorities for winding up, dissolutions, administration or reorganization or for the appointment of the receiver, administrator,
administrative receiver, trustee or similar officer for my /our assets. 4. I/We declare that I/We have not made any payments in cash, bearer cheque or kind along with or in connection with this application to the
executive collecting my/our application. I/we shall not hold Aditya Birla Capital Limited. (hereinafter referred to "ABCL") liable for any such payments made by us to the executive collecting this application. 5. I/We
understand and acknowledge that ABCL shall have the absolute discretion, without assigning any reasons (unless required by applicable law) to reject our application and ABCL shall not be responsible in any manner
whatsoever to me/us for such rejection or any delay in notifying me /us of such rejection and any costs, losses, damages or expenses, or other consequences, caused by reasons of such rejection, or any delay in notifying
me/us of such rejection, of our application. 6.I/We understand and am/are aware that the processing fees collected from me/us by ABCL, is for the purpose of ABCL reviewing this loan application as per its own
parameters and is not refundable to me/us under any circumstances whatsoever, irrespective of whether ABCL sanctions this loan application of mine or not. 7. I/We confirm that I /we shall not use the products or the
credit /loan facility(s) (or any part thereof) for any improper/illegal or unlawful purpose/ activities. 8. I/We shall inform to ABCL regarding any changes in my /our address(s) or my employment or profession. 9.I/We
hereby confirm that I/we am/are competent and fully authorized to give declarations, undertaking etc. execute and submit this application form and all other documents for the purpose of availing the loan, creation of
security and for all the purposes mentioned /required to be done for this. 10. I/We confirm that I/we shall cooperate with ABCL and furnish additional documents and/or shall execute such other documents, if necessary
to enable ABCL to abide by/comply with all other existing /further directives of the statutory /regulatory authorities/any other authority acting under any Law. 11. I/We hereby give consent to the ABCL or its
Authorized Agents and third party service providers to use information/data provided by me to contact me through any channel of communication including but not limited to email, telephone, sms, etc. and further
authorize the disclosure of the information contained herein to its affiliates/group companies or their Authorized Agents or Third Party Service Providers in order to provide information and updates to me on various
financial and investment products and offering of other services. 12. I/We Agree that all personal or transactional related information collected/provided by me can be shared/transferred and disclosed with the
abovementioned parties including with any regulatory, statutory or judicial authorities for compliance with any law or regulation in accordance with privacy policy as available at the website of the ABCL.13.I/We
hereby consent to receiving information from Central KYC Registry through $MS/Email on the above registered number/email address. 14. I/We hereby provide our consent to ABCL to obtain the Applicant(s)
information from Credit Information Company and/or information utility and/or such institution set up under the provisions of law from time to time, as and when required.
IMPORTANT NOTE
• That the receipt of your application form for the loan does not imply automatic approval of your loan by ABCL. ABCL may request additional documents other than those in connection with the application. I/We
confirm that the executive who collected my/our applications/documents has informed me/us and I/we am/are fully aware: 1. That Government Tax as may be applicable from time to time will be charged in
connection with the Loan. 2. That ABCL will not be liable for loss or delay in receipt of the documents. 3. That incomplete/defective applications will not be processed, and ABCL shall not be responsible in any
manner for the resulting delay or otherwise. 4. That the application forms, documents/photographs will not be returned under any circumstances once submitted to ABCL. 5. That approval for the applications is at the
sole discretion of ABCL. 6. That the quantum of the loan will be finally decided by ABCL, and ABCL has not made any commitment to me/us regarding the same. 7. That equated installments (EMI) will be due on
1st/5th of every month (strike out which is not applicable).
• The Most Important Terms and Conditions mentioned above are an indicative list of terms and conditions of our loan products. These Terms and Conditions are further described in our loan agreement under
relevant sections/schedules and therefore should be read in conjunction with those mentioned in the loan agreement.
Ajmer
Place
Applicant's Signature Co-Applicant's Signature
Date
Common Document Checklist - All the submitted documents to be self-attested by the customer
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Additional Documents - Salaried
■ ■
Dully Filled and signed Application Form (with Last 3 months Salary Slip or Salary Certificate
■
cross signed photographs of App/Co- Non-Refundable Fee Cheque ■
App/Guarantor) Latest Form 16
■
■ Photocopy of Property Papers (where Property is ■
KYC Documents of all parties to the loan Identified) Latest 6 months Bank Statement where direct salary is being credited
○ ■ Additional Documents - Self Employed/Professional/Partnership/Company
Identity Proof (Specify) Details of Limits and Loans availed
■
○ ■
■ Partnership Deed & MOA/AOA
Signature Proof (Specify) Copy of PAN Card
Financial Documents for 2 years ■
○ ■
Repayment Track Record (if applicable) ○ List of Directors/Shareholders attested by CA/CS
Proof of Residence (Specify) ITR along with computation
■ ■
○ Bank Verification Form ○ Latest 12 months Bank Statement (Both Business
Proof of Office (Specify) Balance Sheet, P&L, Schedules and Savings)
■
○
Proof of Qualification (Specify)
Latest Loan outstanding statement for Refinance
cases + ○
Tax Audit Report
■
VAT/Sales Tax returns for current financial year
FOR OFFICIAL USE ONLY
Documents Received Self-Certified True Copies Notary Risk category Low Medium High
In Person Verification Carried Out By Institution Details
Identity Verification Done Date Name
Emp. Name AB H A Y S I N G H Code
Emp. Code BG 5 7 9 7 7 9
Emp. Designation
Emp. Branch A j m e r
[Employee Signature] [Institution Stamp]
Aditya Birla Capital Limited
Registered Office: Indian Rayon Compound, Veraval - 362 266, Gujarat | CIN: L67120GJ2007PLC058890.
Corporate Office: One World Centre, Tower 1, 18th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai - 400 013.
For customer care and other queries: care.finance@adityabirlacapital.com
Toll-free no.: 1800-270-7000 | www.adityabirlacapital.com
Terms and conditions apply. Credit at sole discretion of Aditya Birla Capital Limited (ABCL) and subject to credit appraisal, eligibility check, rates etc.
ABCL may use the services of their authorized agencies in servicing the requirements.
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