Stat e Bank Group

Application for International ATM - Debit Card

To T he Branc h Manager State Bank of A. I hold the account no.

with you branch in my sole name/jointly with to be operated on Either or Surv ivor/Any one or Survivor basis. I have been issued a domestic Debit Card bearing Number

/hav e not been issued any Debit Card (delete as applicable). I hereby the apply for an International International Debit Card. Debit Card for I am my use. that I authorize you to block the Domestic Debit Card as long as I use aware International Card can be us ed from India and abroad. B. My name on the card s hould appear as under [This can be full name (not ex ceeding max imum 24 letters), or an abbreviated form of the name of the applicant for example, Bharat Kumar can appear as Bharat Kumar, B. Kumar or K. Bharat]

C.

I furnish the following particulars to be used for identification when I contact the "Help Line" through telephone for reporting los s of International Debit Card

Fathers First Name Mothers Maiden Name** Date of birth DDMMYYYY Year of pas sing SSC YYYY Year of Marriage* ** YYYY

Do not furni sh the surnames example; S R. Tendulkar, the name should be Sac hi n.

if

the

name

is

** In respect of Mother s maiden name, you may furnis h mothers name before m arri age *** If these dates are not r elevant it may be fi lled as XXXX I am awar e that the International Card can be used for al l domesti c trans ac tions and transactions i nvolving foreign exchange permitted under the Forei gn Exchange Management Act and the Rul es framed there under by Reserve Bank of India from time to ti me. I undertak e to use the card in strict com pli ance with the appli cable Exchange Control/Managem ent Regulations and any violat ion thereof will result in cancell ati on of the card and make me liabl e under rel evant provision of the Act/Regul ati ons. I al so undertake to furni sh all the details in res pect of any transaction entered into by me to facilitate any investigation. I hereby authori ze you to recover from my account the cost of the car d and all ot her fees whi ch may be payabl e by SBI to MasterCard (other than transaction fee) for extra-or dinary services rendered by them (example lost/stolen card).

Place Date Name

: : : (Sig nature of Applicant)

Address : Tel. No.: Mobile : e-mail OFFICE USE Acc ount partic ulars & s ignature of Applican t & mode of operation verified. Request for issue of International Debit Card appro ved/dec lin ed for t he reason (delete as applicable) Date Aut horis ed official :

Data for is sue of international Deb it Card forwarded for processing Branc h Name Code Number Da te Authorised official

Call Centre Details Call us Toll free* : 1 600 - 112211

From other than MTNL / BSNL lines in India & abroad at 00-91-80-2560 8470, 2560 8980
Als o pleas e co ntac t the nearest card iss uing bran ch or email us at : sb ica shplus @v snl.net