PUNJAB & SIND BANK

PSB RUPAY KCC DEBIT CARD APPLICATION FORM

Application Serial No.
Branch Code :
Branch Office:
The Branch Manager,
Punjab & Sind Bank
..............................
Dear Sir,
I/we wish to apply for PSB RUPAY KCC DEBIT CARD
I/We understand that my/our existing PSB ATM card will be deactivated, once the PSB RUPAY
KCC DEBIT CARD is issued/applied for.
My/Our details are as under:
1.Title:Mr/Ms/M/S
2.Name of the Customer:
First Name / Middle Name
Surname
3.Card Display Name(As to be embossed on the card)
4.Date of Birth
5.Residential Address:
City /Pin.
Tel. No (with STD Code) / Mobile No;
6.Customer Office Address
City /Pin
7.Tel:with STD Code:
8.Branch Name:
9.Primary Account Type :CC
10.Primary Account No.
11.Secondary Account Type: CC
12.Secondary Account No.
13.PAN/GIR No.
14. AADHAR No.(optional)
15.Declaration:
I/We declare that the above information is correct. I/We authorize Bank to debit my/our Primary Account for all withdrawals using the PSB RUPAY KCC DEBIT CARD 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. I/We undertake to maintain sufficient funds, excluding the minimum balance stipulated, in Primary account.
I/We accept full responsibility for my/our PSB RUPAY KCC DEBIT CARD. and agree not to make claims against Punjab & Sind Bank in respect thereto.
(*Signature of the Customer)
(*In case of joint a/c, all holders should sign Card will be is single name )
(To be filled by the Issuing Branch)
The Details mentioned in the application form including signatures of the applicant and mode of operation of the Primary and Secondary account/s are verified and correct.
(Authorised Official) (Branch Manager)
Date:
PSB RUPAY KCC DEBIT CARD. No. issued Date of Issue