fr;re*fi61-qt{. +6ft. +j*.tS=+ Ar*iF rls-.y ilr : p The Nav Jeevan Go-op. Bank Ltd. ESTD:1985 Head office : Bhawani Saw Mills compound, Furniture 8azar, Ulhasnagar - 421003
APPLICATION EOR - RtPay DEBIT-CIIM-ATM CARD
Br.rnch Date Card Request New Replacement Stolen/L.ost/Damage Renewal
Note : Please Fill the Form in Capital Letters & Tick Mark ( ) as applicable.
. Nnr,c in BLOCK LEITER (As to bc cnrbosstdII on the ATM Card Not more than 1,6 characters including Blank Space) * Account Type : Saving Current Account No. TIIIIITITITI Name of Account Holder *
III I IIIIIIIIIIITI lvlailin Address I IIIIIIIIIIIII I I IITTIIIIIIIII IIII II IIIIIII Pin Code : I II * Tel. No I I Mobile No. I II Ernail ID I rtl I I II IXISTING ATM L]ARD NUMBER TOR SURRENDER TO IHE BANK IIIIIIIIIITITIII * Mandatory Fields (lrisllrg A TM r"rd ?r,iil be duchralerl imnediatelV from tlr date of issunnce of Nru " Rupay" Debit-Cum-ATM Cqrd)
DECLARATION / DEBIT.CUM-ATM CARD UNDERTAKINC
I / we hlv€ r€ad and understood th€ Tetms & conditions, dven on lhe ba& of this application lorm, toveming the usages ol The Nav Jeevan Co-op Bank Ltd. Debit-Cum-ATM Card. I / W. accepl lo be bound by th. said Terms & Conditions or to any changes made therein from time to lime by the Bank at its sole discretion without prior noti.e to me/ us. I /We.onfim thal I/W€ am /are the Sole A.count holdeds).I /We accept Full responsibility for the safe keeping of My / Our Debil - Cum - ATM Card and secret PIN. I /W€'aglee not lo make any cl.ims atainst The Nev Jeevan Co-op B.nk Ltd.,in case oI misuse of the Card and Pin due to my / our Ne8ligence.l /We agre. to pmvid. any infonnation frctrr My/ OurAccountto The Nav Jeevan Co.op Bank Ltd.
Namc ofThe Account Holdcr(s) Signature
BANK USE ONLY
Customer No Application No. Date
Wc recommend issue of Debit-cum-ATM Caid to above mentioned custorner. We ceitify that the account is KYC compliant & Signaturc(s) of account holder(s) has/have been verified. The above details including Mobile No. are updated in the CBS.
Charges Applicable Yes No tl Amount New Debit-Cum-ATM Card No IIIT
Branch Seai ()iti.er Branch Head TERMS & CONDITIONS
I Monin$:'Ihe lsm Bdt' ptuE to lhe TtE NavJ€cv- Corop BankLtd. ATM'rd@ b ll* tl Ba l?. Llfr Th3 b&l shall ha ve rhe pa a ru6r rithr ol etoff & Iien, iftlFl iw oi rny oth€ r Aulond.d TeUs Ma(h& icLlld al tE SrmdEs ol th. BdU', 'Cad tbld6' r.n r b rlE li6vdraEe!, pe*n .! wetl as tulure o. lh. &posit oI ay lirvd & ot!r. (in.ludirE fired Adhoi2ed uer o, ?up.y-OdilATM C d','ATM A..os/ reG6 b rh. AuttDnry ol &poiE) hdd/bja@3lyin8 inany..@unrror rhe ca'd Hol&ds, whdltr in 3intle n.he o, oFftr'n8 - ATM A.Mt th.'CIB'rcE s roCrrdissint Bafthof rh.B-k,.d rlq rks ioint l5 Rup.y-D.bt-AfM C&d S.f.tf Il is sle r6pGibilily oI .rd hold6lo p.*rE lh. cdd in A!6urr lbtu! Ch&gE Any dEnAe i. dE hode oIoFEdon EdlE or.hanSc ol Rupay' ondili@ Alwrrd 6s!e lo t c? RupoyOdil'ATM Cid eily in plart poldt tr 8(rd Elbit-AIM C.d EoBl sn.ll el be.llowed UJB jD. t writrop.hi$ionbsol{hr Fo, p.461 .ny ph)6ral drtc t rugptic slrip/cNPaql ml efo*it to trr,EPlic 6cldr, h..l dan8. or hftrd Rlpry-D.tit.ATM C.d will h . rob€ scn&rd b ih€ bat and , wiEr erl dusla.ytiE Ifthtc,d r!bDle.orm.6d$le itwillbeN;si.l6cd sinv.lid(.rd -y ft6h 6rd ,illb. i5*d o.paytunt ortu6 / ctu Bet. & ftw crd will bc i$ed on.n applcation by card holde. & o handin8 over oltEh inv.lid .rd tur Ene{hhon r, C,B Any s$e.cof ,@ @rd willbe drSeble t8 Ow@rNp o, RuP.y-C@ATMC&d: RuPry Ddit Cm ATM Ced sh.llb{ rhe poperty ol he lillbc lurt.deEd lo oenlof cad Hold6tulo.gcr Rup.y-D.h1-ATV Card v.tdllyi Th. Rlp.y-Debn-ATM ca'd holds dt muihum v.lidity b-k ad ltEBelo. r{e!lorinllE reqliri.B th. rrvie. Th. 86I rsv6 *E ri8ht to di$lo5e in strid Co.6denc, to oltEr ir r Pt nod of Ei6h ytrs 6om tlt dileofissuane orcrd institrnimr ruch itforh*ion oremin8 rhe dd holdq"s deun .r mry be e.Bsary or C.h Wfth&.pd Ltnlt A) Ri6O0- p.r daylF card subi(l to ilSility ol bale in ?proFid. in dlwction with ils p ricip.lion h .ny ATM or Elqhont Fud Tra.sler Cult)tu. Aco6t El C6h withdr&al limn ar odE b k! ATM will be R3 l0@U- Pcr inllaBup tom imlm oI & 2!m/-(our CId Linil) t9. AllhortDtL.Fnsibilty: A) TIE B.nlrh.llnol be cipoBible tu. any l@ or daNte ,in^t die.lly or indn