( Form No. R–I )

APPLICATION FOR AVAILING INTERNET BANKING SERVICES
( For Retail Customers Only)

BRANCH NAME BRANCH CODE
CUSTOMER INFORMATION
PRIMARY
ACCOUNT NO.
CUSTOMER-ID
(As in Primary A/c)
A/C CONSTITUTION
Individual Joint Proprietorship
MODE OF OPERATIONS
Single EOS FOS All Jointly
FIRST NAME MIDDLE NAME LAST NAME
MOTHER’S MAIDEN NAME PAN
DATE OF BIRTH D D M M Y Y Y Y PLACE OF BIRTH
GENDER Male Female MARTIAL STATUS M arried Unmarried Divorcee
ADDRESS PHONE
MOBILE
CITY FAX
STATE PIN E-MAIL
PASSPORT NO. ISSUE DATE ISSUING AUTHORITY EXPIRY DATE
1. If you do not know your customer-ID, contact your Branch. Branch will help you in filling your customer-ID.
2. Passport related information is mandatory for Non-Resident Customers.
3. Mobile Number is mandatory for availing Internet Banking Services. The above mobile number will be Registered for SMS Alerts/SMS Banking facilities .
4. Linked Account Transfer Facility will be provided at Bank’s discretion subject to Terms and Conditions/restrictions for allowing this functionality.
GENERAL INFORMATION
STATUS OF APPLICANT Resident Indian Non-Resident Indian Foreigner
OCCUPATION Business Professional Service Others
TYPE OF CUSTOMER General Staff Ex-Staff Senior Citizen
ANNUAL INCOME Up to 2 Lacs Between 2 Lacs & 5 Lacs Between 5 Lacs & 10 Lacs 10 Lacs & above
I hereby undertake that the information submitted above is correct. I have read the Terms and Conditions applicable for availing Internet Banking
Services, as displayed on the bank’s website http://www.psbindia.com and agree to abide by the same.
Date :
Place: Signatures of the Applicant
DECLARATION
I am aware that the usage of PsbOnline Internet Banking service is governed by the terms and conditions, which are displayed on the website
www.psbindia.com maintained by the bank. I have read the terms and conditions applicable to the bank accounts as displayed on the bank's website and I
agree to abide by the same. I do not use Cyber Cafes to access the PsbOnline Internet Banking Service. I accept that I would be deemed to be aware of the
contents of the Terms and Conditions and that all my rights and liabilities would be governed by the said Terms and Conditions by my act of accessing
on www.psbindia.com. Any changes made by the Bank in respect of Terms and Conditions which are on website are acceptable to me and I shall abide by
the same and the bank need not give me a separate notice in this regard, l also agree that this application shall be treated as an authenticated request for
generating User ID and Passwords/PIN for my use. The User ID and Password/PIN mailers can be mailed to my address provided in the application at my
risk and responsibility. Further I declare that I have the knowledge in the use of Internet. I declare that all the particulars and information given in this
form are true, correct, complete and up-to-date in all respects and I have not withheld any information.
I further understand that I am applying for availing Fund Transfer Facility through PsbOnline Internet Banking. I hereby undertake that I will be
responsible for keying in the correct account number(s) for the Fund Transfer. In no case, Punjab & Sind Bank will be held liable for any erroneous
transaction(s) arising out of or relating to my User-ID, entering wrong Account Number(s) or for such other errors resulted from operations of the
account(s) by me wrongly and loss thereby.
Date :
Place : Signatures of the Applicant
NRI-DECLARATION
I hereby declare that I am non resident Indian of Indian Nationality/Origin. I/We agree that the facility of PsbOnline shall be available only in specified type
of accounts as notified by Bank as eligible for Internet Banking Facility from time to time. I/We do hereby undertake that I/We shall not make available to
any person resident in India, Foreign currency again reimbursement in rupees or in any other manner in India. I/We further undertake that debits to the
accounts for purpose of investment in India and credits representing sale proceeds of investments are covered either by general or special permission of
Reserve Bank of India. I / We further undertake and declare that any request made by me /us through PsbOnline Internet Banking facility for transfer of
fund shall be for the approved bonafide transactions of domestic nature only and in any event such request will not be in contravention to the various
Regulations framed under Foreign Exchange Management Act 1999, Foreign Exchange Management [Deposit] Regulations, 2000 and other rules and
regulations laid down by Reserve Bank of India including Exchange Control Regulations. I/We do hereby indemnify and forever indemnified the Bank
and its successors and assign from and against any and all claims, actions, penalties that may be made, suffered or incurred by the Bank by reason of
non compliance of any of the Terms and Conditions mentioned therein.
Date :
Place : Signatures of the Applicant.
FOR BRANCH USE
I have verified the application form, signatures and mandates for accounts and confirm that applicant is Sole/ Primary holder in all the accounts under
Primary Customer-ID. In case of joint account(s), Letter of Consent has been taken from all joint account holders and attached herewith. Signatures of
First Customer and holders have been duly verified with Bank’s Record. The above Application has been entered in PsbOnline Application Receipt
Register .I have verified and hereby confirm that KYC Norms are fulfilled completely for the account(s) mentioned in the application form.
I hereby recommend for Registration of the customer for PsbOnline Facilities.
ENTRY NO. R ENTRY DATE:
Stamp and Signatures of the Branch Relationship Manager
NAME
PF CODE
BR.CODE
DATE
General Instructions:-
a. Entry No. and Entry Date of Branch PsbOnline Application Receipt Register must be filled.
b. Branches to verify the particulars with data on record in Core Banking.
c. Mobile Number is mandatory for availing Internet Banking Services. The mobile number will be registered for SMS Alerts/SMS Banking facilities .