SUPER SERVICE AGENT

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Photo
c Oxi Super POS c RBL CSP

c Merchant Payment

Prospect ID:

CSP Code:

Link Branch Code:

Link Branch Name:

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:

Doing Business Since:

PERMANENT ADDRESS
Address:
City/Village:

Tehsil:

District:

Pin Code:

State:

Stay in the Village/Town Since:

Registered Mobile No.:

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)

Others (Pls Specify)

ESTIMATED MONTHLY REVENUE

c Less Than Rs. 5000

c Rs. 5000- Rs. 10000

c Rs. 10000- Rs.20000

c Rs. 20000- Rs.30000

c More than Rs. 30000

3. PAYMENT DETAILS
Payment via (tick any one):

c NEFT c RTGS c

In favour of: Oxigen Services India Pvt. Ltd.

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:

4. YOUR BANK DETAILS

Bank Name:

A/c No.:

Branch:

Branch Code:

Nature of Account: c Savings Account

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

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5.MERCHANT ENROLLMENT DETAILS

Nature of Business
Merchant Category Code (MCC) :
MDR :

Debit Card c 1%

Date:

Credit Card c 2%

Monthly Fee : (`) .:

(if any)

Avg. Transaction Size : (`) .

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:

7. RMU/ OXIGEN EMPLOYEE DECLARATION (FOR DIRECT RO)

Acquired By:

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:

Name & Signature (with seal)

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