GCCSL

CUSTOMER INFORMATION FORM Date: 22-01-2025
Applicant Name :
Father's/ Husband's Name :
DOB :
Gender :
Mobile No. :
Landline No. :
Religion/ Class :
Caste :
Occupation :
Higher Education :
Communication Address :
City :		State
Country :		Pin :
If Communication Address is same as Permanent Address:
Permanent Address :
City :		State
Country :		Pin :
Email-Id :
Spouse Name :
Anniversary Date :
Mother's Name :
Proof of Identity :
Proof of Address :
Photo Upload :	File size must be less than 50 KB ( jpeg/ jpg/ png )
Signature Upload :	File size must be less than 20 KB ( jpeg/ jpg/ png )
Proof of Identity Upload :	File size must be less than 512 KB ( jpeg/ jpg/ png )
Proof of Address Upload :	File size must be less than 512 KB ( jpeg/ jpg/ png )
Introducer Details
Introducer's Customer ID :
I certify that i have known the Applicant for the past :	Months Years
Declaration: I / We have understood the Society's rule for any type of account and other add-on facilities opted for and agree to comply with and be bound by them as they are in force now and from time to time for such accounts. Further I/ We undertake to intimate the society in writing within two weeks of any change in my address due to relocation or any other reasons, along with the proof of new address.
For Office Use
Account Type :
Account Number :