APPLICATION FORM FOR ATM / DEBIT CARD Affi Passport Size Photograph Alf Passport Size Photograph ‘Branch/ Distintive No, 1 {for Photo Based | (for Photo Based Personalized Crd | Personalised Date I only) Card only) Request for issuance of ATM/Debit Card (Please Hick ‘Request Type (Tick any one] st Ty (Tick New () RENEWAL/REPLACEMENT [_] | ADD-ON [_} jequest_(Tiek any one] PERSONALISED L]__| NONPERSONALISED L] ‘Network Partners (Tick any one] [MASTERCARD] RUPAY oO visa C1) Services (Tick any o DOMESTIC oO INTERNATIONAL a Varlants (Tek any one CASSIE PLATINUM [ PUaTINUM INTERNATIONAL GoLo* (1) ‘SIGNATURE*[_] | SELECT*(_] | OTHER ~PLATINUD& PLATINUM INTERNATIONAL VARIANT s AVAILABLE WITH RUPAY & MASTERCARD ONLY GOLD & SIGNATURE VARIANT IS AVARKABLE WITH VISA NETWORK ONLY ‘SELECT OEBIT CARD IS AVAILADLE WITH RUPAY NETWORK ONLY 1. (a) Name of Account Holder (in Block Letters) 1. (b) Name of 2 Account Holder (in Block Letters) {Please attach soparate shoot in case of more secount holders) 2. (a) Name of Account Holder (In Block Letters) {To be embossed on card ~ Max 20 characters) 2, (b) Name of 2 Account Holder (in Block Letters) (Tobe embossed on card = Max 20 cheracters) 2; (c) Name of 1" Add-On Card Holder (in Block Letters)” (To be embossed on card = Max20 characters) Z (a) Name of 2" Add-On Card Holder (in Block Letters)” (To be embossed on card ~ Max 20 characters) For Add-On Card, please mention relation withthe Account holder and Date of Birth of Aad-On Cardholder. [F* Add-On Cardholder's relation with Account Holder. DOB aps | Tey BF Add-On Cardholder's relation with Account Holder Dos |o 7 Ter 3. Mobile No 4, E-mail ld 2 5. Secondary Account Linking: YES [} (If¥es, Please fll below Details) No [] Details of Main and Linked Accounts: Detall of Type of Account ‘Account Number Account (58 /cA) MAIN LINKED LINKED w linked accounts can be used for Card based transactions NOTE: The Main and li 6, Select address for delive Please ensure Address Is up ry of card: (I) Branch Address C(I dated in Bank Account for smooth d Taked Accounts should bein the same nome and capacity. The Permanent Address} (ll) Communication Address* I] ry of Debit CardNOTE: toca Stns ‘ards which are undelivered to the Permanent / Communication Address shall be returned to the Branch Address. The customer has to collect the same within 60 days of card delivery at branch address after which the card shall be HOTLISTED/ CLOSED. In this scenario, fresh application needs to be submitted for new DEBIT Card, General Terms & ‘Gardholder shal Bank shall 1 | Ensure safety of his/her debit card/pin, Not be held Tale Tor any Toss cdised By a technical Breakdown of the system, Change his/her PIN frequently through any of the networked ATMs of PN or through Reta internet Banking Have no responsiblity In respect of the goods/senices provided by the merchant, Notify the bank immediately after knowing loss/thet of debit Not be held responsible for any dispute the cardholder may have with any merchant establishments. In case of any disputed transaction bank shall caren | credit account of cardholder on receipt of refund from Merchant Estabichment tough banking chanel ‘Bear the Toss sustained (any), up to the time of receipt oF 4 | notification by bank at designated place about loss/thett of | 4 debit card [tits discretion can take appropriate steps to terminate use of eard for any valid reason, Maintain sufficient balance In his/her aeeount to perform successful transactions How to Be Safe When Using Your Debit Card at ATMs & POS 1. Never keep your PIN number & card together 2. Do not write down or disclose your PIN number to anyone Inthe ATM, while entering your PIN number, cover the keypad to avoid revealing your PIN to anyone around Change your PIN number regularly as per your convenience: ‘Once you have memorized the CVV number of your card please erase/blacken the CVV/CVD number to avoid misuse. Register your mobile number for the SMS Alerts service to get instant alert messages about any activity on your account, 7. Check your account statements/SMS sent by your bank regularly to cross check account details and transaction You cam restrict the card transaction limit and usage through Internet banking service Terms & Conditions, Offers, Facts & Charges Are Subject to Change as Per Bank/RBI Guidelines from Time to Time. Visit sow pnbinla.in for complete details Do not share user id / password/OTP/CVV/PIN/Card details, With anyone, even if the person claims to be a bank official!” Declaration: 1. agree to abide by the terms and conditions related to ATM/Debit Cards a laid down by the Bank in the Bank's website as www.pnbinida.in 2. {shall be using my ATM/Debit Card only if agree to the terme & conditions stipulated by the Bank for the same. 3. {indemnify the Bank for al valid transactions undertaking through my ATM/Debit Card. 4. lundertake to safeguard my ATM/Debit Card and not share my PIN with anybody to ensure Its safety 5. undertake that all transactions undertaken through the ADD-ON ATM/Debit Cards issued as per my request would be treated at par with transactions undertaken by me. ‘The details furnished above are true tothe best of my knowledge and belie | agree to pay an amount of Rs for Issuance of Debit Card and applicable annual fees, if any. Signature of 1" Account Holder Signature of 2 Account Holder Signatire of 1" Add-On Cardholder ; Signature of 2" Add-On Cardholder FOR OFFICE USE ONL! Details of accounts and signatures of the account holder (s)s given above have been verlied & Card issued as per Tequew 1. Signature of Authorised Personnel 2. Signature of Authorised Personnel PNB 1068-Ri - 130/13 (100) LP 5