~--------------------------------.- ..

~~-"6"-~/~ <nTi <);- ~ ~ l<:i" APPLICATION FOR INTERNATIONAL DEBIT-CUM-ATM CARD I ATM CARD*
(Please fill in capital letters only) IC/19
- \ .-~~.~--~ 'I'1t 'R 3<'Ii\ui~ 0fR if; fuv: 'fTI! I NAME TO BE EMBOSSED ON THE CARD

J,- Bank of.lndia~

m;:~:::~-
..
+.&!I:i,7~~ q;Ji ~ (~IDU 'ffi;;rrQ','TT)I CARD NUMBER (to be filled by the Bank)
§!slimonsmp. 6<yon£ ~

~/Branch

, , -,
_ ~ Fcicrtur I PERSONAL PARTICULARS
'fIl1:m/~/~ :, , , , , , , , , , , , , , , , , , , , , , ,
Name: Mr.lMrs.lMs.
(~'fIl11 SURNAME) ('!Mlr 1Tlf I FIRST NAME) (ml!1Tlf I MIDDLE NAME)

"l"1 ~ I Date of Birth :CD CD ITIIJ

:srq; 'fflT I MAILING ADDRESS: , , , ! , , , , , , , , , , , , , , , , , , , , ,
, I I I I I I -, , , , I I I I , , , , , I I I , ,

, , , , , , , , , , , , , , , , 'fiFr/Pin:~

~ I Phone: ~ I Office: , , , , , , , I I I , f.!c!ml Resi : I , , , , , , , , , ,

~I Mobile:'
, , , , , , , , , , , , , , ,., , , , , ,.,
"

t-Jffi I E-mail :, I I I I I , I I I , , I , " , , , , , , , , ,

-- -
-
\'Il:~.ISr.
-- -
~/Branch
-r~
~ I ACCOUNT - PAR.TJCULARS

~ q;r If<fiKIType'* 1ID(fni"&ll/ Accl. Number m~q,'j./DateOpened

01
02
03
04
05
06
(ri q;r 1FIiR- Ofi'R!/~aTIiT)'*1 Type: SB/CD/OD)**
~ ~ 'R <ittm 'ifill (~3R ft<fr iF ~) -it ~ >tu ~ ~ % I (~1l!f> %g <fITI f.mH <'flT11t)***
My Option for the third language (beside English & Hjndi) for ATM screen display is (pI. tick one)***

o
o
orrrffi I Bengali

I Malayalam
0 ~
0 >melt/
IGujarati 0~I
0R /
Gurumukhi 0 ~I
0~
Kannada

'*'
lfff!!R'Il[ Marathi Tamil /Telugu

~ -erorr WIT Wq;nft

t fif; $. ~
mjt ~ I ~ ~ ~~-'ffl-~ m/~ m 'R ~ ~ mif <Fr ~ trr W~
~(Mj~ffRw.ITarrimifq;)~~~~Cfi\fWrr~T~~-e-~:W~~~-'ffl-~m/~m~q;G(Mj~iF
mm"@fi ~iF~ ~~~ ~Cfi'r~ q;G q;r ~WlTWq;nfttl
I declare that the above information is correct. I acknowledge receipt of terms and conditions applicable to Starlinks International Debit-cum-ATM Card/
ATM Card and I have read and accepted the same. I hereby request the Bank to issue me a Starlinks International Debit-cum-Atm Card/ATM Card and to recover
the applicable charges/fees from time to time to the debit of my primary Account
" ~,~~~~ ~~~-'ffl-~'filt/~'filt-e- ~~ 3l'f.tW;jjl!]m~wr-wr3it[{~
~<IDi\-q~~*~:wRTW~'R~~~Cfi'r~WIT ·/~tl
I,without prejudice to the above, accept Bank's Lien on all my deposits present and future held in~e primary account as well as in any other deposit account
whether linked to Starlinks International Debit-cum-ATM Card/ATM Card facility or not.
~~W;;rr;rffitfif;:W~~~-'ffl-~m/~m~~~'R~~-e-"¥.ffcmlrr;r~m~Cfi\~~1
I understand that upon issuance of the Starlinks International Debit-cum-ATM Card to me, the existing ATM Card Linked to my account will be deactivated.

~/Date: ~/Signature

~~~~~~~~~.~~~~~~-------
~/Branch
~
~
if; lW-Ifirq;- ~ 'fiT ~
m'<f <ti\ ft;r1rr~ I 'fiTi ;mU
~
'flG %g ~
~ '*'~ ~
m"'i.lCode No,-:--:-
fctcRuTf CfiT~ <ti\
---:-_
ft;r1rr~, ~ ~ ~:S3!T
I / The Primary account of the customer is conducted satisfactorily and we confirm having verified the above
~ m ~~ 'fiT ~ ~

particulars. Proof of holding secondary accounts is obtained wherever necessary. Approved for issuance of card,

~/Date: 'I111lIl~if;~llR/Signature of Branch Manager ifiiilCode:

~/Note : 31f.rc!R:IT
(Gffill) 31f.r<m:IT (~) ~ iF ~ -it ~ ~ '!it ~ ~ %I
In case of Non-Resident (External) I Non-Resident (Ordinary) accounts, secondary accounts are not permitted .
•~ "ffi'L 1" ~ ;:ffi "f>R ~ II Strike out whichever is not applicable .
••~ '1m ~/&Tit iF fcIq{or iF ~ &Tit 'I'T "lI'flR ft;r@ II "Please mention type of account as-per the passbook/statement of account.
~ ~ iF ~ '1m ~/&Tit 'I'T fcIq{or >IT ~ ~ I/Please also present the passbook/statement of account for verification .
•••~ ~ iF 'r'i ~ iF ~..;t ~/Facility to be provided solely at the Bank's discretion.
PAP. 12,00,000 Form 110-2009