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OSSA Application Form PDF

This document contains a merchant enrollment form for Oxigen Services to register a new merchant. It collects personal details of the merchant such as name, address, contact information, and business details including nature of business, estimated monthly revenue, and bank account details. The merchant is required to submit identity and address proof documents and declare that they do not have a criminal record. An Oxigen mobile wallet will also be opened for the merchant. The form requires signatures of the merchant and enrolling Oxigen employee to confirm all information provided and reviewed identification documents.

Uploaded by

Manindarsing Dhanawat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
308 views2 pages

OSSA Application Form PDF

This document contains a merchant enrollment form for Oxigen Services to register a new merchant. It collects personal details of the merchant such as name, address, contact information, and business details including nature of business, estimated monthly revenue, and bank account details. The merchant is required to submit identity and address proof documents and declare that they do not have a criminal record. An Oxigen mobile wallet will also be opened for the merchant. The form requires signatures of the merchant and enrolling Oxigen employee to confirm all information provided and reviewed identification documents.

Uploaded by

Manindarsing Dhanawat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SUPER SERVICE AGENT

TM

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

TM

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

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