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First Name *

Last Name *

Name As Per PAN Card *

Father Name *

Mother Name *

Email *

Phone Number *

Mobile No Linked With Aadhaar(only for Video KYC from bank)

• Yes
• No

Marital status

• Single
• Married

PAN Number

Date Of Birth As Per Pan card

Aadhaar No.

Personal Email *

Current Address

City

State

Pin code

Duration at Current Address(In yrs)

Permanent Address As per Aadhar

Salaried - Company Working for

Student's College Name

Products *Select ProductCredit CardLoansDeposit SchemesInsuranceTata Sky D2H

status ICICI Per

Businessmen with 6 Lakh

• Yes
• No

ICICI Saving Account Number(For Student applicant only)

Additional Comments

Checkboxes *

• I am applying for this product from Svatantr (Subsidary of Miyaank Nostalgic Pvt Ltd). I allow SSPL (MNPL) team for call back and mail for relevant content.

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