Indian Overseas Bank
Credit Card Division
763, Anna Salai, Chennai 600 002
Phone : 91-44-2851 9574

Application For IOB VISA Credit Card

OFFICE / BUSINESS ADDRESS
Designation ...........................................
Employer’s Name ................................
Employed Since ..............................Yrs
Confirmed Yes No
Postal Address ......................................
..................................................................
City .......................... Pin .........................
State.........................................................
Telephone...............................................
STD Code...............................................
Fax. No. ...................................................
RESIDENTIAL ADDRESS
..................................................................
..................................................................
City .......................... Pin.........................
State ........................................................
Residence Since ..........................Yrs
Telephone No. ......................................
STD Code ................................................
Mobile No. ..............................................
E-mail ID ................................................
IT PAN .....................................................
Voter ID No. ............................................
Residence is own / Company Lease /
Private Rented / Parent Owned
Living with Parents Yes No
Earlier Employment Details, if any
Name of the Employer
Duration of Service.........................Yrs.
If residence is own,
residing since ................................. Yrs.
How old is your house ..................Yrs.
Do you own Regn. No.
If under loan,
amount of
loan
Driving Licence
No.
Passport No.
Car
Two Wheeler
House
Others
Valid upto
Issued at
I have read / understood and hereby agree to be bound by the Terms and Conditions governing IOB VISA CREDIT CARD 2006 (as furnished separately). The particulars furnished above are true to the best of my knowledge and belief and I agree to inform the Bank, changes if any, as & when they occur. I agree to pay the membership / Annual fee & other charges which will be fixed by the Bank, from time to time. I agree to settle all dues arising under IOB VISA CREDIT CARD that may be issued in my name and Add-On-IOB VISA CREDIT CARD that may be issued in the name(s) of my family members in accordance with the Terms and conditions as existing and as amended from time to time. I hereby authorize you to contact my employer / Bankers as and when you feel the need to do so in connection with this application / my transactions under IOB VISA CREDIT CARD. I have neither applied for nor obtained IOB VISA CREDIT CARD so far. The use of card will be deemed to be acceptance of the terms and conditions. I also hereby authorise you to inform / get the details of my transactions including default of payment that may occur to / from any of the Credit Card issuers, other Banks, Financial Institutions, Credit Information Bureau of India Ltd. (CIBIL) and any other organisation as the Bank may deem fit without obtaining any further oral or
written consent from me.
Place :
Date : Signature of Main Card Holder (Applicant)
DECLARATION
APPLICATION FOR IOB VISA CREDIT CARD
Application to be completed in full. USE BLOCK LETTERS
Photo to be printed on card (if yes, additional charges, if any, towards printing
of photo will be debited to the account of the applicant) Yes No
Date of Sex
Birth
Marital
Status
Professional
Qualification
No. of
dependant/s
DD MM YY M
F
Married
Single
U.G.
Graduate
Others
P.G.
Professional
CONFIDENTIAL
CA/SB/Other A/cs (specify) Account No. Branch Bank
Deposit No. Amount Branch Bank
Particulars of Loan, if any, type/No. Amount Outstanding Bank/Branch
Description of property Value Description of other Value
and Address Income/Investments
.......................................... ........................ .......................................... .........................
.......................................... ........................ .......................................... .........................
.......................................... ........................ .......................................... .........................
.......................................... ........................ .......................................... .........................
I am a Resident / Non Resident Indian Resident Non Resident
PERSONAL PARTICULARS
Name in Full Surname First Name Middle Name
Mr. / Ms.
Father’s / Husband Name
Mother’s Maiden Name
Name to be embossed on IOB VISA CREDIT CARD (Not to exceed 19 letters
including space. Please leave one box space between each name)
BANKING DETAILS
Application No.
Indian Overseas Bank
Credit Card Division
763, Anna Salai, Chennai 600 002.
Phone : 91-44-2851 9574
Please affix
Colour Photo
Passport Size
Please do not
Sign.
A/c No.
Br. Code Serial No.
Salaried Banking & finance Self Employed Firm
Govt. Sector Manufacturing C.A. Proprietor
Public Sector Exports Doctor Partnership
Private Sector Consultant Others
Sub-category Advocate
IT Sector Engineer
Others
If Staff of Indian
Overseas Bank Roll.No.
Date of
Joining
Present
Designation Branch/Dept.
EMPLOYMENT DETAILS
ASSIGNMENT / NOMINATION FOR CARD HOLDER INSURANCE
I ............................................................................. (Name of the Applicant) do hereby
assign the money payable by United India Insurance Company Ltd. in the event of my
accidental death to ............................................. (Name of the Nominee) who is my
......................................... (relationship to the applicant). If the nominee is minor, name
and address of the guardian...............................................................................
........................................................................................................................................
I hereby authorise the Bank to adjust the IOB VISA CREDIT CARD dues, if any, from
the insurance claims settled. I further declare that the nominee’s receipt shall be
sufficient proof of discharge to United India Insurance Co. Ltd.
Name of Witness ..................................................
Signature of Witness ............................................
Address of Witness .............................................
..............................................................................
Date this ............. day of .........20 ........... at ............
......................................................
(Signature of Applicant)
Card No.
...................................
...................................
...................................
...................................
Issued by(bank name)
..................................
..................................
..................................
..................................
Year of Issue Expiry Month,Year Limit
.................... ........................... ..................
.................... ........................... ..................
.................... ........................... ..................
.................... ........................... ..................
OTHER CREDIT CARD DETAILS
Add on card required Yes No If yes, particulars of Add on Cards
1.Name of the Add on Applicant .............................................................................
Date of Birth Occupation ...............................
Relationship To Applicant Spouse Parent Major Son Major Daughter
If Employed in our Bank, Roll No. ......................................
2. Name of the Add on Applicant .............................................................................
Date of Birth Occupation ...............................
Relationship To Applicant Spouse Parent Major Son Major Daughter
If Employed in our Bank, Roll No. ......................................
ADD ON CARD DETAILS
ASSIGNMENT / NOMINATION FOR SPOUSE INSURANCE
I ............................................................................. (Name of the Applicant) do hereby
assign the money payable by United India Insurance Company Ltd. in the event of my
accidental death to .................................... (Name of the Nominee) If the nominee is
minor, name and address of the guardian .............................................................
...........................................................................................................................................
I hereby declare that the nominee’s receipt shall be sufficient proof of discharge
to United India Insurance Co. Ltd. Bank reserves the right to adjust the monies settled
towards IOB VISA CREDIT CARD dues,if any, from applicant/card holder.
Name of Witness ..................................................
Signature of Witness ............................................
Address of Witness .............................................
..............................................................................
Date this ............. day of .........20 ........... at ............
.....................................................
(Signature of Spouse)
Attested by
......................................................
(Signature of Applicant)
Payment Due Date Option 10th of Month Last day of Month
Option of Payment Debit to my account above mentioned Payment by Cheque
I hereby request you to issue the above Add on cards and I/we shall be jointly and
severally responsible for the use of card/s and settlement of the bills.
Signature of the Add on Card Holders
1. ..........................................................
2. ..........................................................
..............................................................
Signature of Main Card Holder (Applicant)
Annual (Rs.) Annual (Rs.)
1. Gross Salary ........................... 4. Deductions .............................
2. Business Income ........................... 5. Business Liability .............................
3. Other Income ........................... 6. Other Liability .............................
(If any, specify) ........................... (If any, specify) .............................
Total (1+2+3) A ........................... Total (4+5+6) B .............................
Net Income (A-B) ...........................
I shall settle my IOB VISA Credit Card bills by debit to my SB/CA/CC/NRE/NRO A/c.
with .......................... branch of I.O.B. in the name of ............................................
maintained since ........................ yrs.
I hereby authorise you to debit the above mentioned account as and when IOB VISA
CREDIT CARD bills are raised.
Correspondence / Bills may be addressed to
Office Residence
Enclosures Proof of other Income
Salary Certificate (Proforma Enclosed) Proof of Property
Proof of Business Income Proof of Income from Property
IT / WT AO Any other Document (Please specify)
SETTLEMENT DETAILS
FINANCIAL PARTICULARS
For BR. Code No.
Office Use
(Tick appropriate box and furnish the relevant information)
I have verified the details furnished in the application as per KYC norms.
The applicant is a customer of our Bank for the past .........................
years, maintaining an average balance of Rs. ......................................... in his/her
SB / Current / NRE / NRO a/c .................................................................and the
dealing with us have been satisfactory.
VIP OTHERS
The applicant is not a customer of our Bank, but is known to us for the
past ........................... years.
The applicant is good for Rs. .............................................. (specify net worth)and
has deposit of Rs..................................... with us (specify encumbered
/ Unencumbered).
We recommend issue of IOB VISA CREDIT CARD as requested for with an overall
ceiling limit of Rs. ........................................
Add-on IOB VISA CREDIT CARD as requested for may be issued / may not be issued.
Additional information, if any :
.....................................................................................
Signature of Branch Manager in-charge
Name : .........................................................................
S.S. No. : .....................................................................
Name of Branch : ........................................................
Date : ............................ Br. Code No. : .........................
Decline / Issue IOB VISA CREDIT CARD with / without Add on facility with
overall ceiling limit of Rs. ..........................................................
Date : Chief Manager / AGM / DGM / GM
BRANCH RECOMMENDATION
(To be filled in by Credit Card Division)
Card No.
Main Card
Add on Card
Add on Card
Issued on Valid upto
ORDERS OF CM / AGM / DGM / GM (IN CASE OF EXCEPTIONS)