Credit Card

l confirm and agree that we may give any information in connection with this application (including Documentation Required
your personal information) to any service provider (whether located in or outside of India) for the l Identity proof (Any one) : Passport, Photo Pan card, Driving License, Voter ID Card, Photo Ration Card
purposes of providing any service to you in connection with this application (including data l Address Proof (Any one) : Passport, Telephone Bill, Ration Card, Electricity Bill, Driving License, Life/Medical Insurance Policy, Rental Agreement,
Apartment Allotment Letter
processing) or credit card product features;
l agree that you will inform us when there is any change in your occupation, employer or the status of
Financial Documents
your residency in India. If we ask, you will also give us the documents to prove such a change;
l Salaried : Latest one month salary slip
l consent to each of Standard Chartered PLC and its subsidiaries and affiliates (including each branch l Self Employed : Latest IT Returns with computation of Income/Certified Financials, Last Business Continuity proof
or representative office) (“Standard Chartered Group”) its officers, employees, agents and advisers The Bank may use the services of Direct Sales Agents (DSA’s) for sourcing, selling, marketing, documentation and other association activities.
disclosing information relating to you (including details of the accounts, products or any security
interest) to: FOR BANK USE ONLY
n our head office and any other member of the Standard Chartered Group in any jurisdiction
(“permitted parties”); DSR ID R Ctrl No
n professional advisers, service providers or independent contractors to, or agents of, the permitted
parties, such as debt collection agencies, data processing firms and correspondents who are
under a duty of confidentiality to the permitted parties; DSR ID C ID No
n any actual or potential participant or sub-participant in relation to any of our obligations under our
banking agreement between us, or assignee, novatee or transferee (or any officer, employee,
agent or adviser of any of them);
DSR ID S Scanning Date
n any credit reference agency, rating agency, business alliance partner, insurer or insurance broker
of, or direct or indirect provider of credit protection to, or any permitted parties;
n any court, tribunal or authority (including an authority investigating an offence) with jurisdiction D D / M M / Y Y Y Y
over the permitted parties; a merchant or a member of a card association (for instance, Visa or Memo Line
MasterCard) where the disclosure is in connection with use of a card;
n any authorised person or any security provider;
n anyone we consider necessary in order to provide you with services in connection with an account;
FCU
l declare that all foreign exchange transactions entrusted to us from time to time do not involve and are Pickup Sample No
not designed for the purpose of any contravention or evasion of the provisions of the Foreign
Exchange Management Act, 1999 or any rule, regulation, notification, direction or order made under MID Code CT1
that Act. You also agree to give us any information or document as will satisfy us about the purpose of
a transaction. You also understand that if you do not fully comply with any requirement, we can refuse
to undertake a transaction and may report the matter to RBI. Relying upon this declaration, we may
not insist on your giving specific further declarations for future foreign exchange transactions; LEZ Code CT9

l confirm that no insolvency/bankruptcy proceedings have been initiated against you nor have you
ever been adjudicated insolvent;
l confirm that you have received, read and understood our Customer Terms and the applicable Corporate ID CT10
documents referred to in Part A of our Customer Terms forming our banking agreement which are For internal use only
available at any of our branches or on our website at www.standardchartered.co.in and you agree to
be bound by them. You acknowledge that you are bound by any variation we make to these Company Code CT11
documents, in accordance with our banking agreement. In particular, you understand that by
entering into our banking agreement you give indemnities, authorizations, consents and waivers and
agree to limitations on our liability; Promo Code CT12
l if you are applying for any Insurance product, you agree to be bound by the terms & conditions Stamp
applicable that product which are made available to you separately;
l acknowledge that we may decline your application. If this happens, no contractual relationship will Source Code CT13
arise between us and we reserve the right to retain the documents you submitted to us with your
application;
Name
OCC Code CT14

Annual Income (P. A) Gross Annual Income CT15

Unmatched benefits
Date Branch Code CT16
for your various needs
Please affix D D / M M / Y Y Y Y

photo here Back calling done Yes No

Ver: Nov_10
Special Handling
CPV RV 01 02 04 Doc check Not refer

Documents attached
Payslip Salary Certificate Form 16/A, Appointment letter, Increment letter, HR letter ITR / Surrogate
Signature
In any banking relationship, time and convenience are important qualities that are well appreciated by any customer. We have designed Permanent Address (if different from residential address) Same as Residential Address Contact Details of a Friend/Relative not living with you
this form so as to make it easier and hassle-free for you when it comes to applying for our comprehensive range of banking services. At Name
Standard Chartered, we look forward to knowing you well, and serving you better.
Please fill all fields in BLOCK LETTERS, use BLUE / BLACK ball pen only.
Please use wherever applicable Telephone Number

Sec 1 Please tell us about yourself (Primary Applicant)

Area Code
Salutation/Title Mr Mrs Ms Other
City Would you like Standard Chartered to contact you or send communication material regarding our sales offers to you through telephone, SMS or email
Full Name
Yes No

First Name Middle Name Last Name State

Sec 2 Which Credit Card would you like to apply for
Name to be embossed on Card
Type of Credit Card
Pin Code
Emirates Platinum Platinum Elite Manhattan Platinum Platinum Rewards Gold Rewards
Date of Birth
Super Value Titanium Business Card BREEZE BANKING Titanium
Nature of Employment If you have opted for Emirates Platinum Credit Card then please provide your existing Skyward membership number if any
D D / M M / Y Y Y Y
Pvt Ltd Co Public Ltd Govt Sector Public Sector Undertaking Self Employed MNC Others
PAN Number Mobile Number
Nature/Type of Business
Software/IT Finance/Insurance FMCG/Retail Eng/Infrastructure Textile/Leather * If you are applying for the BREEZE BANKING Titanium Credit Card, please provide your choice of 3 reward categories:
01 - Dining 02 - Retail Fashion 03 - Fuel 04 - Groceries and Supermarkets 05 - Entertainment
Are you an existing customer
Yes (Please provide your, existing Standard Chartered Bank account, Credit Card number or Loan Account number before proceeding to Section 2 if your particulars have not changed) Others 06 - Electronics and Technology 07 - Travel 08 - Hotels 09 - Utility 10 - Health and Wellness
Standard Chartered Bank Account Number Standard Chartered Bank Card Number
Name of Employer/Name of Business (if self employed) * If you are applying for the BREEZE BANKING Titanium Credit Card and would like to choose an image from the catalogue, please enter the Image code

No (Please complete the fields below)

Designation Would you like us to debit your current/savings account with us for payment of your credit card dues?
Type of Identity document Yes No
Passport Driving License Other
If yes, please provide account number
No. of years in current Organisation / Business
ID document Number Nationality

Y Y M M If yes, please indicate minumum or full balance

Gender Marital Status
Married Office Address (Individual)/Regd Office (for Business) Minimum Amount Due Total Amount Due
Male Female Single

Residential Status
Sec 3 Would you like a Supplementary Credit Card
Resident Indian Non Resident Indian Foreign National Others

Education Status Yes No

Up to Higher Secondary Graduate Post Graduate Diploma Professional
If Yes then please fill the supplementary card form with ID and Address Proof of Supplementary Card Applicant

Others
City
Sec 4 Please consider these valuable services
Residence Type (Ownership of residence)
Self Owned Rented Company Provided Paying Guest Accomodation / Hostel Others Online Banking Yes No SMS Alerts Yes No Electronic Statements Yes No
State (If you opt for electronic statement, no physical statement will be sent. However, a physical statement will be provided on request through phone banking)
Duration of stay in current residence No. of Dependents

Pin Code Sec 5 Would you be interested in signing up for the following products
Y Y M M
Residential Address
Savings Account Yes No Insurance Products

Preferred Address for Communication Preferred Contact time for verification Current Account Yes No Credit Protection Plan Yes No
Residential Address Office Address am/pm to am/pm Mortgage Yes No Credit Shield Plan Yes No
Telephone Number 3-in-1 Account Yes No
Home Office / Direct Number (If you have opted for the above product, please complete our insurance
(If you have opted for the above products, our representative will get in touch with you) provider's form available with our representative)

Landmark
Area Code Area Code Declaration
Board Number Extension Number

City By signing this application you:

Area Code l represent and warrant that all information (including any documents) you have given to us in

State
Telephone Number at Permanent Address connection with the application is correct, complete and not misleading. (If this is not the case
you may be personally liable);
Area Code
l authorize us to verify any of the information you have given to us or your credit standing from anyone
we may consider appropriate (such as an authority or credit reference agency or Credit Bureau);

*00171100000001*
Pin Code
Email address (please provide your primary email address)
l authorize us to authenticate any credit card details you give us by conducting test authorizations with
the issuer of that credit card;