APPLICATION FORM FOR ATM cum
VISA DEBIT CARD

The Chief Manager/AGM ______/______/___________
United Bank of India DD/MM/YEAR
_____________Branch
Dear Sir,
Being desirous of availing the facility of using ATM cum Visa Debit card, I/We furnish the information below.
Name(s)
Date of Birth
Nationality _____________________ Resident/Non Resident
A/C. No. SB/CD/OD
(CD a/c. card will be issued to proprietor/proprietress only.)
Address_ ______________l
l
__________ ________ Pin No.
Address_(O) _____________ l
l
___________________ Pin No.
Tel. No. (O)

Cell No.
Email ID j
I/We hereby declare to abide by the rules/terms & conditions as applicable to United Bank of India International Visa
Debit Card holder. I/We will follow the stipulated guidelines for usage of United Bank Debit Card and comply with
the existing as also the modifications, if any made by the bank from time to time without reference to me/us.
Signature/s

(In case of Joint a/c. all holders must sign)
…………………………………………FOR BANK USE ONLY…………………………………………………….
Card No._____________________________________.
Date: _______________.
Above signature(s) verified
____________ Sign of authorized officials with seal
& signature serial no.__________.o
“Received the UBI International Visa Debit Card welcome kit, in sealed and good condition”. (Applicable for Pre-
Activated Card).
_________________ ___________________
(Signature) (Signature)
www.unitedbankofindia.com Toll Free No. 1800 345 0345 SMS UBI to 56365