Application Form for “Centcash Debit Card”

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APPLICATION FORM FOR “CENTCASH DEBIT CARD”

CENTRAL BANK OF INDIA For Branch Use: -

Application Sr.No. Card No.

BRANCH: ______

PERSONAL PARTICULARS

1. Name: Mr./Mrs./Ms. : (Surname) (First Name) (Middle Name)

2. Name to be embossed on (Not more than 19 card: letters)

3. Father/Husband Name :

4. Date of Birth 5. Gender : Female : Male DD / MM / YYYY

6. Details of existing cards Name of Bank Type of Card Card No. : i ii

7. Mailing Address :

8. Permanent Address :

9. Phone No. Residence Office Mobile :

10.E-mail

ACCOUNT PARTICULARS

Branch A/c A/c No. Title of A/c Type * Primary A/c Secondary A/c (i)

(ii)

(iii) * (Type: SB/CD/OD)

Declaration:

I declare that above information is correct. I request Central Bank of India to issue a Centcash Debit Card to me. I have read and understood the terms and conditions governing the usage of centcash debit card. I accept to be bound by the said terms & conditions or to any changes made therein from time to time by the bank at its sole discretion without any notice to me.. I unconditionally and irrevocably authorize the Bank to debit my account with an amount equivalent to the fees and charges for use of my Centcash Debit Card. I, without prejudice to the above, accept Banks lien on all my deposits, present and future, held in the Primary A/c as well as any other Deposit account/s.

I understand that upon issuance of Centcash Debit Card, my previous ATM card of Central Bank of India will be deactivated. I undertake that the utilization of the Centcash Debit Card would be strictly in accordance with the Exchange Control Regulations and in the event of any failure to do so I am aware that I am liable for action under Foreign Exchange Management Act (FEMA) 1999. I undertake to fulfill and abide by all guidelines issued by Central Bank of India from time to time regarding the International use of Centcash Debit Card and foreign currency transactions.

Date: Applicant’s Signature

I/We irrevocably authorize the Bank to issue a Centc Card to above applicant Name Signature (i) (ii) (iii) (In case of joint/firm account, application form must be signed by all the joint account holders/partners)

For Branch use only:

- The primary account of the customer is conducted satisfactory and we confirm having verified the above particulars/signatures. - We also confirm having verified the above particulars / signatures / proof of having secondary accounts / and authority to operate these accounts got verified from the concerned branch. - The applicant is eligible for issuance of Centcash Debit Card. Approved for issuance of Centcash Debit Card.

Date:______Branch Manager

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Data entered in Card Generation Software, File No.______sent to ATM Switch Centre through FTP/E-mail.

Date:______Officer