1
ATM F-1
BANK OF MAHARASHTRA
(H.O. : Lokmangal 1501 Shivajinagar, Pune 411005.)
Branch MICR No. Serial Number

ATM CARD APPLICATION FORM

(Please fill in block letters) (Please put (tick) in appropriate box)
To,
The Branch Manager,
Bank of Maharashtra,
____________ Branch,
Dear Sir,
I/We wish to apply for the ATM (Automated Teller Machine) Card. The details are as under.
PERSONAL INFORMATION
1) Name
(as to be embossed on the card)
2)
Name in
SURNAME
FIRST NAME
MIDDLE NAME
Full
3) Date of Birth DD-MM-YYYY
4) Address (Please put (X) in the box below indicating your choice of address to which correspondence is to be sent)
RESIDENCE ADDRESS ( )
OFFICE ADDRESS ( )
PIN
PIN
Telephone Number :
Telephone Number :
OCCUPATION / BUSINESS INFORMATION
5) Current Employer/Business Name ___________________________________________________
Nature of business ___________________________________________________
Designation __________________________ Length of Business/Service ________________________
Business Registration No. ____________ Annual Salary/Business Income _________________
Other Annual Income _________Permanent Income Tax No. ________ Ward _______ Circle __________
FINANCIAL INFORMATION
6) Primary Account details (the Saving Bank or Current Account)
Type
Account Number
Balance
Joint Holder's Name/s (If Any)
2
7) If any other Credit/ ATM Card held Sr. No
Name of the Card Issuing Institution
Valid Up To Limit, if any
8) Nationality : Resident status (State whether Indian Resident or Non Resident)
9) Document for positive identification (Passport/Driving License/Identity Card/Ration Card/Voter's I-Card etc.)
Issued By
No
Date of Issue
10) DECLARATION :
I/We declare that the above information is correct. I/We have read and understood the terms and conditions of the ATM Card Scheme as annexed to this application. I/We authorise the Bank to contact my/our employer or any source to obtain any further information that may be required. I/We hereby authorise the Bank to issue to me/us an ATM CARD as requested and debt my/our above mentioned Primary account for all withdrawals to be using the card and also to recover the Bank's charges/fees as applicable from time to time. Without any prejudice to above, I/We accept the Bank's lien on my/our all deposits, present and future, held in the above mentioned Primary Account.
Authorised Signature/s 1.
2
3
FOR USE OF THE ISSUING BRANCH BRANCH APPLICATION SR. NO.
The details mentioned in the application form are verified by us and the application is sanctioned and forwarded to ATM Card Cell, Mumbai, for issuance of the Card.
Basis of eligibility (Please put tick in appropriate box) Verification of 1. Salary Certificate 2. Income Tax Return
3. Wealth Tax Return
Signature of Branch Manager, Signature Code No. Seal of the Branch Name and Designation Date
TO BE FILLED IN BY ATM CARD CELL, MUMBAI
1. Application Received on 2. ATM Card No.
3. Card Deposit on : 4. Information sent to the SPNS Switch on :
(Only in the case of Mumbai branches)
Seal & Signature of Authorised Official ATM Card Cell