Application Form for Debit Card

Branch Name _____________ Date of Application______________

Name (Person to whom card is to be issued)

Mr./Mrs./Ms _______________________________________________________________

Date of Birth_______________________________________________________________

Father’s/Spouse Name ______________________________________________________

Name Desired on Debit Card__________________________________________________

Address:

(O) __________________________________________________________________

______________________________ Pin _______________________________

Address:

(R) __________________________________________________________________

______________________________ Pin ________________________________

Tel. No. (R) _________________________ Tel. No. (O)_____________________________

Mobile No__________________________ e-mail ID _____________________________

Details of Primary Account Number:-

I would like to receive my Card and PIN Mailer at (Please tick one option)

i) Residential Address.

ii) Office Address.

iii) Will collect personally from the Branch

Nomination details

Name of the Nominee ______________________Relationeship ______________

If nominee is minor Date of Birth______________________________________

Name of the Guardian _______________________________________________

DECLARATION FOR DEBIT CARD UNDERTAKING

I/We have read and understood the Terms and Conditions governing the usage of

Union Bank Debit Card. I/We accept to be bound by the said terms and Conditions or

to any changes made therein from time to time by the Bank at its sole discretion

without notice to me/us. I/We confirm that I/We are the sole account holder(s) or

have the required mandate to operate all the accounts linked to the Debit card singly.

I/We accept full responsibility for my/our Debit Card and agree not to make any

claims against Union Bank of India in respect there to. I/we agree to provide any

information from my/our account to Union Bank of India.

Date:___________ Signature of First Applicant:________________________

Place:__________ Signature of second Applicant:_______________________

(In case of joint Account)

(Debit Card is issued in joint accounts where mode of operation is either or survivor / anyone

or survivor. It is not issued to trust accounts and accounts having credit facility)

FOR BRANCH USE ONLY

Address, signature of Customer and Mode of Operation of the account(s) verified in

Finacle system. The conduct of the account during the last six months is

satisfactory/It is a New Account. We hereby issue the Debit Card.

Card Number : _______________________________________________________

Signature of the Issuing / verifying Authority: __________________________________

Name of the issuing /verifying Authority: _____________________________________

P.A. no. / User ID __________________________

Date: ______________

Branch: ______________