ACCOUNT OPENING FORM

SECTION A: MAIN APPLICANT

Your Personal Details

Salutation Miss Mr Mdm Mrs Dr

Name (as in NRIC or Passport)

First Name

Middle Name

Last Name

Alias

Date of Issue Date of Expiry

Town/City of Birth

Country of Birth

Marital Status Single Married Others (Please specify:______________________________________________________________)

Mother’s Maiden Name (for verification purpose)

Additional Information

Senior Public Figure Declaration [Politically Exposed Persons (PEP)/International Organizational PEP Declaration]*

1) I/We hereby declare that:

I/We do not hold, have never held and am/ are not actively seeking to hold or being considered for the position of a senior public figure.

I/We currently hold have held, the position of senior public figure.

5) I hereby confirm that I hold do not hold a Permanent Account Number (PAN) issued by Indian taxation authorities in my name in India.

PAN

* “PEP” means a close associate, domestic PEP, family member, foreign PEP or international organization PEP; “Close associate” means a natural person who is closely connected to a PEP, either

socially or professionally; “Domestic PEP” means a natural person who is or has been entrusted domestically with prominent public functions; “Family member” means a parent, step-parent, child,

step-child, adopted child, spouse, sibling, step-sibling and adopted sibling of the PEP; “Foreign PEP” means a natural person who is or has been entrusted with prominent public functions in a foreign

country; “International organization” means an entity established by formal political agreements between member countries that have the status of international treaties, whose existence is

recognized by law

in member countries and which is not treated as a resident institutional unit of the country in which it is located; “International organization PEP” means a natural person who is

or has been entrusted with prominent public functions in an international organization; “Prominent public functions” includes the roles held by a head of state, a head of government, government

ministers, senior civil or public servants, senior judicial or military officials, senior executives of state owned corporations, senior political party officials, members of the legislature and senior

(DDMMYYYY)

(DDMMYYYY)

Addresses

Residential Status

Self Owned Rent

Country: Postal Code:

Communication Address (if different from above)

Block/House No.: Street Name:

Unit Number: #

Premise Name:

City: State:

Country: Postal Code:

Contact Details

Residential Office

Fax Mobile

Mandatory for Internet Banking facility

Email

Education & Employment Details

Highest Education

No education / primary University O/A levels / Diploma Professional / MBA

Others (Please specify: _____________________________________)

*

/Business Salaried Housewife Retired

Student Unemployed Others (Please specify: _____________________________________)

*Please fill in the following additional information if you are Self-employed:

Is the business self started or family owned?

Number of years since start of business: ________________________________________________________________________________________________

Customer shareholding percentage in the business: ______________________________________________________________________________________

Estimated average annual turnover of the business: ______________________________________________________________________________________

Any other information that you deem relevant: ___________________________________________________________________________________________

Amount in words _____________________________________________________________________________________________________________________

Amount in figures Tenor months Rate

Interest Payout Quarterly Half yearly Annually On maturity

Maturity Instructions

Renew Principal/ Principal and Interest for months

Credit ICICI Bank Current Account

Credit my account with other bank

Account No

Bank branch code Swift Code

Bank Name

Page 4 of 12

Applicant funding the Account

Main Applicant Joint Applicant Others (Please specify: ___________________________________________)

Anticipated relationship size

Less than S$30,000 S$30,000 – S$99,999 S$100,000 – S149,999 S$150,000 – S$299,999

S$300,000 – S$649,999 S$650,000 – S$1,299,999 S$1,300,000 – S$6,500,000

More than S$6,500,000 (Please specify:__________________________________________________________________________________________)

Anticipated no of banking and investment transactions within next year

less than 5 5-10 10-20 20-50

more than 50 (Please specify:___________________________________________________________________________________________________)

Registered address - 9 Raffles Place, #50-01 Republic Plaza, Singapore 048619 Company Reg No.T03FC6380G

* The Fixed Deposit, without the option of premature withdrawal, does not have premature withdrawal facility i.e. the Fixed Deposit cannot be

closed by the depositor before expiry of the term of such deposit. However, the Bank may allow premature withdrawal of these deposits in

following exceptional circumstances: in the event of any direction from any statutory and/or regulatory authority or deceased claim settlement

cases. In the event of premature withdrawal of these deposits under abovementioned exceptional circumstances, the Bank will not pay any

interest on the principal amount of the deposit. Any interest credited or paid upto the date of such premature closure will be recovered from the

deposit amount.

Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the Account Holder’s TIN for each

country/Reportable Jurisdiction indicated. Countries/Jurisdictions adopting the wider approach may require that the

self-certification include a tax identifying number for each jurisdiction of residence (rather than for each Reportable Jurisdiction).

If the Account Holder is not tax resident in any country/jurisdiction (e.g., because it is fiscally transparent), please indicate that on

line 1 and provide its place of effective management or jurisdiction in which its principal office is located.

Country/Jurisdiction of Tax Residence TIN If no TIN available, enter Reason A, B or C

1)

2)

3)

Note: If you have indicated above tax residence in the United States, please also provide a completed and signed Form W-9

Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above

1)

2)

3)

Wire Transfer Amount with currency/GIRO

Debit ICICI Bank Current Account No.

Amount with currency

Registered address - 9 Raffles Place, #50-01 Republic Plaza, Singapore 048619 Company Reg No.T03FC6380G

1 Please tick [√]only one box

Either

I Confirm that I am a “US Person”

If you are a US person, please provide your US Taxpayer Identification number (TIN):

You will also need to complete the W-9 Form and provide necessary supporting documents

1. A citizen or permanent resident of the United States (e.g US Green Card holder or someone who meets the requirements to be considered a resident under

the ‘substantial presence test’) or

2. Any other person that is not a foreign person (as defined under US federal tax law)

i) I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the

Account Holder’s relationship with ICICI Bank Limited, Singapore Branch setting out how ICICI Bank Limited, Singapore Branch

may use and share the information supplied by me.

ii) I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable

Account(s) may be provided to the tax authorities of the country/jurisdiction in which this account(s) is/are maintained and

exchanged with tax authorities of another country/jurisdiction or countries/jurisdictions in which the Account Holder may be

details to IRAS or close or suspend my account.

vi) I certify that I provide the information on this form and to the best of my knowledge and belief the certification is true, correct,

and complete including the taxpayer identification

I undertake to advise ICICI Bank Limited, Singapore Branch promptly of any change in circumstances which affects the tax

residency status of the individual identified in Part 1 of this form or causes the information contained herein to become incorrect

or incomplete, and to provide ICICI Bank Limited, Singapore Branch with a suitably updated self-certification and Declaration

Registered address - 9 Raffles Place, #50-01 Republic Plaza, Singapore 048619 Company Reg No.T03FC6380G

Registered address - 9 Raffles Place, #50-01 Republic Plaza, Singapore 048619 Company Reg No.T03FC6380G