Application form for BANK OF BARODA INTERNATIONAL DEBIT CARD
I wish to apply for Bank of Baroda International Debit Card. Name of the Branch
My/Our Account Type Account Number
I have an ATM card no. (leave blank if not applicable) issued to me
and linked to the account. I would like to link our savings account to the debit card also.
I confirm that I have the required mandate to operate the account singly.
I/We authorize Bank Of Baroda to issue a Debit cum ATM card to me/us
I/We understand that upon issue of a debit card to me/us, the existing ATM card of Bank of Baroda’s standalone ATM if any, may be deactivated.
I/We further unconditionally and irrevocably authorize you my/our account annually for Debit Card fees/Charges.
The particulars are as under:
1.Name
Date of Birth Gender Male Female
Name as required on card
(Not to exceed 20 characters) (No Nicknames) (Please leave one blank space in between each name)
2. Residential Address
City Pin Code
3. Office Address
City Pin Code
Tel. No(O)
Mobile No. E-Mail
4. PREFEERED ADDRESS FOR DELIEVERING DEBIT CARD/PIN MAILER : OFFICE RESIDENCE
DECLARATION/DEBIT CARD UNDERTAKING
I/We have received, read and understood the terms and conditions governing the usage of the Debit Card . I/We accept to be bound by the said terms and conditions and to any changes made therein from time to time by the Bank at its sole discretion without any notice to me/us. I confirm that i am the sole account holder or have the required mandate to operate the account linked to the Debit Card singly and that I/We have completed 18 years of age. I/We understand that upon issue of Debit Card to me/us, the existing ATM card of Bank of Baroda’s standalone ATM linked to my/our account will be deactivated.
I/we understand and undertake that the usage of the Debit Card shall be strictly in accordance with the Exchange Control regulations and in the event of any failure to do so, I/We will be liable for action under the Foreign Exchange Management Act, 1999 and the amendments thereof stipulated by Reserve Bank of India from time to time.
I/We accept full responsibility for my/our Debit Card and agree not to make any claims against Bank Of Baroda in respect thereto.
(Applicant’s Signature) (Other Account Holder/s Signature)
(In case of joint account holders, all account holders shall put their signatures)
Date : Branch Code :
For use in Branch
Name of the Officer
Signature
Signature verified by
Eligibility verified by