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~~-"6"-~/~ <nTi <);~ ~ l<:i" APPLICATION FOR INTERNATIONAL (Please fill in capital letters only) 'I'1t 'R 3<'Ii\ui~ 0fR if;

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DEBIT-CUM-ATM

CARD I ATM CARD* IC/19

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fuv: 'fTI! I NAME

TO BE EMBOSSED ON THE CARD

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Bank of.lndia~
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'ffi;;rrQ','TT)I CARD NUMBER

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~/Branch

'fIl1:m/~/~ Name: Mr.lMrs.lMs.

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I Date of Birth
ADDRESS:

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Fcicrtur

I PERSONAL

PARTICULARS

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:srq; 'fflT I MAILING

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m~q,'j./DateOpened

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I ACCOUNT - PAR.TJCULARS 1ID(fni"&ll/ Accl. Number

01 02 03 04
05

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- Ofi'R!/~aTIiT)'*1 Type: SB/CD/OD)** ~ ~ 'R <ittm 'ifill (~3R ft<fr iF ~) -it ~ >tu ~ ~ % I (~1l!f> My Option for the third language (beside English & Hjndi) for ATM screen display is (pI. tick one)***

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Bengali

I Malayalam

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IGujarati Marathi

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Gurumukhi

Tamil

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Kannada

/Telugu

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~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:

~/Branch

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~/Signature

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I / The Primary account of the customer is conducted satisfactorily and we confirm having verified the above

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

~/Date: ~/Note :

'I111lIl~if;~llR/Signature

of Branch Manager

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(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 .

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II "Please mention type of account as-per the passbook/statement of account.

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I/Please also present the passbook/statement of account for verification . to be provided solely at the Bank's discretion.

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PAP. 12,00,000

Form 110-2009