Application Form For International Debit Card
Branch Name_____________________
Date of Application
Name: (Person to whom card is to be issued)
Mr./Mrs./Ms._______________________________________________________
Date of Birth________________________________________________________
Father’s/Spouse Name______________________________________________
Name as Desired on the International Debit Card
In Block Capital Letters (Maximum upto 18 characters)
Address ____________________________________________________________________________
____________________________________________________________________________
__________________________________________________Pin_______________________
Tel. No. (R)_____________________ Tel. No. (O)__________________________
Mobile No.______________________E-mail ID:___________________________
Details of Primary and Secondary account Number: -
Type of A/c.
Branch Name
Category of A/c. (SB, CA)
16 Digit Account Number
Primary
Secondary
Name of the Nominee_____________________Relationship______________________
If Nominee is Minor-DOB_____________Name of Guardian_____________________
(nominee details are required only for settling Insurance claim in unfortunate event of accidental death)
For Additional Card: - Name (Person to whom card is to be issued).
Mr./Mrs./Ms._______________________________________________________
Date of Birth________________________________________________________
Father’s/Spouse Name______________________________________________
Name of Add on Cardholder as Desired on the Union Debit Card
(Maximum upto 18 characters)
Tel. No. (R)_____________________ Tel. No. (O)__________________________
Mobile No.______________________E-mail ID:___________________________
[International Debit Card is issued only for accounts where mode of operation is self/either or survivor/any one or survivor. It is not issued to Minors/ trust accounts/ Companies/ Partnership/ Associations and against borrowal accounts].
DECLARATION/INTERNATIONAL DEBIT CARD UNDERTAKING
I/We have read and understood the Terms and Conditions governing the usage of Union Bank International Debit-cum-ATM Card. I/We accept to be bound by the said terms and Conditions or to any changes made therein from time to time by the Bank at its sole discretion without notice to me/us. I/We confirm that I/We are the sole account holder(s) or have the required mandate to operate all the accounts linked to the Debit card singly. I/we understand that on the issue of International Debit Card to me/us the existing ATM Card linked to my/our account will be deactivated.
I/We accept full responsibility for the safe keeping of my/our International Debit Card and the secret PIN. I agree not to make any claims against Union Bank Of India in case of misuse of the Card and PIN due to my negligence. I/we agree to provide any information from my/our account to Union Bank of India.
Date:___________ Signature of First Applicant:________________________
Place:__________ Signature of second Applicant:______________________
FOR BRANCH USE ONLY
Signature of Customer and Mode of Operation of the account(s) verified. The conduct of the account during the last six months is satisfactory/It is a New Account. We hereby recommend issuing the International Debit Card.
Signature of the verifying Authority________________________________________
Name of the verifying Authority: ___________________________________________
P.A Number__________________________Branch_____________________________
Date: _______________