Indian Overseas Bank

Credit Card Division

763, Anna Salai, Chennai 600 002.
Phone : 91-44-2851 9574

I am a Resident / Non Resident Indian

Resident
PERSONAL PARTICULARS
Name in Full
Surname
First Name

APPLICATION FOR IOB VISA CREDIT CARD

Application to be completed in full. USE BLOCK LETTERS

CONFIDENTIAL

Application No.
Br. Code

Non Resident
Middle Name

Mr. / Ms.
Fathers / Husband Name
Mothers 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)

Serial No.

Please affix
Colour Photo
Passport Size
Please do not
Sign.

A/c No.
Description of property
and Address

Value

.......................................... ........................
.......................................... ........................
.......................................... ........................
.......................................... ........................

Description of other
Income/Investments

..........................................
..........................................
..........................................
..........................................

Value

.........................
.........................
.........................
.........................

Photo to be printed on card (if yes, additional charges, if any, towards printing
BANKING DETAILS
of photo will be debited to the account of the applicant)
Yes
No
CA/SB/Other A/cs (specify) Account No.
Branch
Bank
Professional
Marital
No. of
Date of
Sex
Qualification
Status
dependant/s
Birth
Deposit No.
Amount
Branch
Bank
U.G.
P.G.
DD MM YY
Married
M
Graduate Professional
Single
F
Others
Particulars of Loan, if any, type/No.
Amount
Outstanding
Bank/Branch
OFFICE / BUSINESS ADDRESS
RESIDENTIAL ADDRESS
Designation ........................................... ..................................................................
DECLARATION
..................................................................
Employers Name ................................
I
have
read
/
understood
and
hereby
agree to be bound by the Terms and Conditions
City .......................... Pin.........................
Employed Since ..............................Yrs State ........................................................ 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
Residence Since ..........................Yrs the Bank, changes if any, as & when they occur. I agree to pay the membership /
Confirmed
Yes
No
Postal Address ...................................... Telephone No. ...................................... Annual fee & other charges which will be fixed by the Bank, from time to time. I agree
STD Code ................................................ to settle all dues arising under IOB VISA CREDIT CARD that may be issued in my name
.................................................................. Mobile No. ..............................................
and Add-On-IOB VISA CREDIT CARD that may be issued in the name(s) of my family
City .......................... Pin ......................... E-mail ID ................................................ members in accordance with the Terms and conditions as existing and as amended
State......................................................... IT PAN ..................................................... from time to time. I hereby authorize you to contact my employer / Bankers as and
Voter ID No. ............................................ when you feel the need to do so in connection with this application / my transactions
Telephone...............................................
Residence is own / Company Lease / 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
STD Code............................................... Private Rented / Parent Owned
conditions. I also hereby authorise you to inform / get the details of my transactions
No
Fax. No. ................................................... Living with Parents Yes
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
Earlier Employment Details, if any If residence is own,
any other organisation as the Bank may deem fit without obtaining any further oral or
Name of the Employer
residing since ................................. Yrs. written consent from me.
Duration of Service.........................Yrs. How old is your house ..................Yrs.

Do you own

If under loan,
Regn. No. amount of Driving Licence
loan
No.

Passport No.

Date :
Valid upto
Issued at

I ............................................................................. (Name of the Applicant) do hereby

assign the money payable by United India Insurance Company Ltd. in the event of my

EMPLOYMENT DETAILS

If Staff of Indian
Overseas Bank

Signature of Main Card Holder (Applicant)

ASSIGNMENT / NOMINATION FOR CARD HOLDER INSURANCE

Car
Two Wheeler
House
Others
Salaried
Govt. Sector
Public Sector
Private Sector
Sub-category
IT Sector

Place :

Banking & finance

Manufacturing
Exports

Roll.No.

Self Employed
Firm
C.A.
Proprietor
Doctor
Partnership
Consultant
Others
Advocate
Engineer
Others
Date of
Present
Designation Branch/Dept.
Joining

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 nominees receipt shall be
sufficient proof of discharge to United India Insurance Co. Ltd.
Name of Witness ..................................................
Signature of Witness ............................................
Address of Witness .............................................
...................................................... ..............................................................................
(Signature of Applicant)
Date this ............. day of .........20 ........... at ............

OTHER CREDIT CARD DETAILS

ASSIGNMENT / NOMINATION FOR SPOUSE INSURANCE

Issued by(bank name) Year of Issue Expiry Month,Year

Card No.

...................................
...................................
...................................
...................................

Limit
.................................. .................... ........................... ..................
.................................. .................... ........................... ..................
.................................. .................... ........................... ..................
.................................. .................... ........................... ..................
ADD ON 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

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 nominees 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 Spouse)
Signature of Witness ............................................
Attested by

Address of Witness .............................................

If Employed in our Bank, Roll No. ......................................

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)

SETTLEMENT DETAILS
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.
For
BR. Code No.
Correspondence / Bills may be addressed to

Office

Office Use

Residence

Payment Due Date Option

Option of Payment

10th of Month

Last day of Month

Debit to my account above mentioned

Annual

FINANCIAL PARTICULARS
(Rs.)
Annual

1. Gross Salary

........................... 4. Deductions

Payment by Cheque

......................................................
(Signature of Applicant)

..............................................................................
Date this ............. day of .........20 ........... at ............

BRANCH RECOMMENDATION
(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 :

(Rs.)

.....................................................................................

.............................

Signature of Branch Manager in-charge

2. Business Income ........................... 5. Business Liability .............................

Name : .........................................................................

3. Other Income
(If any, specify)

........................... 6. Other Liability

.............................

S.S. No. : .....................................................................

...........................

.............................

Name of Branch : ........................................................

(If any, specify)

Total (1+2+3) A

........................... Total (4+5+6) B

Net Income (A-B)

...........................

Enclosures
Salary Certificate (Proforma Enclosed)
Proof of Business Income
IT / WT AO

Decline / Issue IOB VISA CREDIT CARD with / without Add on facility with
Proof of other Income
overall ceiling limit of Rs. ..........................................................
Proof of Property
Proof of Income from Property
Any other Document (Please specify) Date :
Chief Manager / AGM / DGM / GM

(To be filled in by Credit Card Division)

Card No.
Main Card
Add on Card
Add on Card

Br. Code No. : .........................

............................. Date : ............................
ORDERS OF CM / AGM / DGM / GM (IN CASE OF EXCEPTIONS)

Issued on

Valid upto