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,/CAR.) /I./HABA/K Is/Dei) It: Lokiiangal, SH!/a/JI AIID,'

This document appears to be an application for a Visa debit card from a bank in India. It requests basic personal information from the applicant such as name, date of birth, address, phone numbers, and account details. The application asks the applicant to specify which accounts they want the debit card linked to and whether they want additional cards for other users.

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yash amit
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
690 views

,/CAR.) /I./HABA/K Is/Dei) It: Lokiiangal, SH!/a/JI AIID,'

This document appears to be an application for a Visa debit card from a bank in India. It requests basic personal information from the applicant such as name, date of birth, address, phone numbers, and account details. The application asks the applicant to specify which accounts they want the debit card linked to and whether they want additional cards for other users.

Uploaded by

yash amit
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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I

I
AX6/PCR/VISA DC/09 APP L CATION

Branch Code No I I | | J(co BR)hber edupbvbrarch NO.

(ll.o.: LOKIIANGAL, 1501, SH!\a\JI \,\CAR. tU\E .111 005)


]\I.\HABA\K I IS\DEI}IT (]AIID,' RT]PA! DEBIT CARDi
PERSONI],ISED C.{RD APPLICdTION 1lo be f led bv the customerl
D D M [4

t we w sn \o app y lot the ata11a"4 vlSA DebtCard.l,/ly/O!r dela ls a,e rs unde|


{PLEASE FILL THE APPLICATION IN BLOCK LETTERS ONLY)
FI]LLNAMEOFAPPLICANT

2) NAME TO BE E|,,18OSSED oN THE CARD (not to exceed 19 chaGcters):

3) DATE OF B RTH (DD-1,4['i-YYYY) : SexrM!/Fil


4) ADDRESS FOR colvlN4uN|CAT oN AS PER THE BANK RECORDS (Forany Correspondence or 10 send PIN [4a]ei)

CTY

STD CODE & TEL NO


MOBILE NO.
E [,IAIL

5) a) PR I.4ARYACCOUNT DETA LS (as appeared on the passbook or slatemenl)

AccoUNT TYPE (Tqlbelow the bo4


a. NcA .0,\-
(/)
L oPEN- ! O, rv- r sraFF cc n
SCHEME CODE

ACCOUNI NUMBER:

BALANCE OFTHEACCOUNT OPERATION INS'RUCTIONS SELF. E/S,ANY ONE/ SURVIVOR

JOTNT HOLOERS',NAIIIE (lF ANY)


i)
PLEASE SPECIFY ADD-ON CARD
2
REOUESTEDYES/NO

bl sECONDARYACCOUNT DETA LS (as app€ared on the passbook o'statement)l

(/) scuE[iE coDE


AccoUNTwPE (Tick belowthe box)
savtNcAccouNl ! cunneuncccutr ll rT-[---r
Accou NT NLlL'IBER

BALANCE OF THEACCOUNT OPERATION INSTRUCTIONS SELF, E/S,ANY ONE/ SURVIVOR

JOINTHOLD€RS' NAME (IFANY) r)


PLEASE SPECIFYADD ON CARD
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