Card Issue
Application Details
Is ISIC Card
Application entry Date
*
Application No
*
Employee No./SE Code
FFMC Branch
Card Issue Type
Primary Card No
Card Holder Name
Card Details
Funding Type
Tran. Fund Type
#
Currency
*
Card Type
Amount (FC)
*
Card Rate Date
Conversion Rate
Conversion Amount
Commission &
Charges(INR)
*
Other Charges (INR)
Pay Amount (INR)
Payment Mode
*
AXIS A/c No.
Cheque No
Bank
Branch
Address
FWC Details
Contract No.
Contract Rate (eg. 999.9999)
Waiver Details
Waiver
*
IS_SPFC
*
Passport Details
Passport No
*
Passport Type
*
Expiry Date
*
Place of Issue
*
Details of Travel
Country of Travel
*
Type of Travel
*
Date of Travel (dd/mm/yyyy)
*
Funded By
*
Days of Travel
*
Personal Details
Is Customer Exist
Customer Id
*
Full Name
*
(First Name)
(Middle Name)
(Last Name)
Date of Birth
*
Gender
*
Nationality
*
Marital Status
No of Dependants
Mother's Maiden Name
*
Name On Card
*
Residence
Residential Address(Current)
*
Destination City (LOR)
*
Pin Code
*
Telephone No
*
Destination State (LOR)
*
Country
*
Send SMS Alerts
*
Mobile Number with ISD Code
*
Statement Throu Email
*
Email
*
Residential Address(Permanent)
City
*
Pin Code
*
Telephone No
State
*
Country
*
Dispatch Address
*
Residency Since
*
Residency Type
*
Office
Office Name
Office Address
City
*
Pin Code
*
State
*
Country
*
Office Phone
Office Phone EXTN
Office Email
Insurance
Insurance Required
Days to be Insured
Premium Amount
FATCA DETAILS
Country of Birth
*
Country of Tax Residency
*
TIN/PAN NO
*
FATCA CLASSIFICATION
Classification
*
Sub Classification
*
Document Type
*
Document
*
Nomination Details
Nominee Name
Age
Relation
First Nominee
Second Nominee
Third Nominee
Other Details
Voter ID No
Driving Licence No
PAN/GIR No
NSDL Name
Source City (LOS)
Source State (LOS)
GST Number
Please Tell us about your work
Nature of Employment
Profession
Type of Industry/Business
Course Details
Education
*
University Name
*
Course Pursued For
*
Please Fill this section if you are salaried
You Work For
Name of Company
Designation
Years at Current Job
Please fill this section if you are self-employed
Your Firm is
Designation
Years at Current Business
Capital Investment (Rs. in Lakh)
Years at Previous Business
Annual Turnover (Rs. in Lakh)
Tell us About your Bank
Bank Name
Bank Address
Branch Name
City
Pin Code
Nature of Account
No of years with the bank
Are you customer
of AXIS Bank?
Nature of Account
AXIS Bank
Cust ID
Other Bank Details
Please tell us about your income
Income per Annum
Investment Details
Verification of Documents
Remarks (max 500 chars)
Maker Remark
Super Checker Remark
(*) - Mandatory Fields
(#) - Applicable if funding type is Both INR and FCY
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