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c Oxi Super POS c RBL CSP
c Merchant Payment
Prospect ID:
CSP Code:
1. PERSONAL
Date of Birth: D D M M Y Y Y Y Gender : c Male c Female
Full Name:
SHOP DETAILS
Name of Outlet/Shop:
Outlet/Shop Address:
Area of Shop
City/Village:
Tehsil:
Pin Code:
State:
STD Code:
sq.ft
District:
Registered Mobile No.:
Tel.:
E-mail ID:
PERMANENT ADDRESS
Address:
City/Village:
Tehsil:
District:
Pin Code:
State:
STD Code:
Tel.:
KYC DOCUMENTS
Accepted Address Proof: c Aadhaar c Voter ID c Ration Card c Driving License c Passport
ID No.
Accepted Identity Proof: c Aadhaar c Voter ID c Pan Card c Ration Card c Driving License c Passport
ID No.
*KYC-As part of KYC Procedures, attach self attested photocopies of identity, Address &
2. NATURE OF BUSINESS
c Telecom Shop
c Medical
c Fancy Store
c Stationary
Kirana (Grocery)
3. PAYMENT DETAILS
Payment via (tick any one):
c NEFT c RTGS c
Amount: (`)
APPLICATION FEE
Amount: (`)
(in words)
Drawn on:
Date:
Date:
NEFT/RTGS/Transaction ID:
Bank & Branch:
ENROLLMENT FEE
Amount: (`)
(in words)
Drawn on:
NEFT/RTGS/Transaction ID:
Bank & Branch:
A/c No.:
Branch:
Branch Code:
c Current Account
City:
Held for:
Years:
Oxigen Services (India) Pvt. Ltd. | Building No.94, Sector 32, Institutional Area, Gurgaon-122 001, Haryana (India). Customer Care Number.:0120 7151000
E-mail: feedback@myoxigen.com | Website: www.myoxigen.com | An ISO 9001: 2008 Certified Company
TM
Debit Card c 1%
Date:
Credit Card c 2%
(if any)
6. RO DECLARATION
i) I have read and understood the terms & conditions provided with the form and I agree to all the terms and conditions listed on the Oxigen Retailers' website.
(www.myoxigen.com/ro-termsandconditions.php). I accept these as binding on me and received copy of T&C.
RO Stamp
ii) I have been provided a copy of the detailed terms & conditions as well.
iii) I have understood all particulars of the investment plan chosen by me, trading process, margins and related terms
& conditions at which services are provided by OSI as applicable on this date and as amended from time to time.
iv) I confirm that the information(s) & particulars supplied by me are correct in all respects.
Name & Signature (with seal)
v) I hereby declare that I do not have a Criminal record.
vi) I hereby agree, to open an Oxigen mobile wallet, along with the KYC documents submitted
with this form, on my registered Mobile Number
Name of Person:
Designation:
Date:
c DSA
c Direct
RMU/Oxigen Employee
I hereby confirm that this form was signed by the RO in my presence and
I have physically seen and verified the document(s) attached here with their respective original(s).
DSA Name/Oxigen Employee:
DSA/Employee Code:
Note : *Address Proof should match with either Retail Outlet Address or Permanent Address
*Retailer should sign on all the pages of ROE form with rubber stamp
Oxigen Services (India) Pvt. Ltd. | Building No.94, Sector 32, Institutional Area, Gurgaon-122 001, Haryana (India). Customer Care Number.:0120 7151000
E-mail: feedback@myoxigen.com | Website: www.myoxigen.com | An ISO 9001: 2008 Certified Company