Stat e Bank Group

Application for International ATM - Debit Card

To
T he Branc h Manager
State Bank of
A.

I hold the account no.

with you branch in my sole name/jointly with

to be
operated on Either or Surv ivor/Any one or Survivor basis. I have
been issued a domestic Debit Card bearing Number

/hav e not been issued any Debit Card (delete as applicable). I

hereby

apply for an International

Debit Card for

my use.

I authorize you to block the Domestic Debit Card as long as I use

the

International

Debit

Card.

am

aware

that

International Card can be us ed from India and abroad.

B.

My name on the card s hould appear as under [This can be

full name (not ex ceeding max imum 24 letters), or an
abbreviated form of the name of the applicant for example, Bharat
Kumar can appear as Bharat Kumar, B. Kumar
or
K. Bharat]

C.

I furnish the following particulars to be used for identification

when I contact the "Help Line" through telephone for
reporting los s of International Debit Card

Fathers First Name

Mothers Maiden Name**
Date of birth
DDMMYYYY

Year of
pas sing SSC
YYYY

Year of
Marriage* **
YYYY

Do
not
furni sh
the
surnames
example;
S R. Tendulkar, the name should be Sac hi n.

if

the

name

is

** In respect of Mother s maiden name, you may furnis h mothers name before
m arri age
*** If these dates are not r elevant it may be fi lled as XXXX
I am awar e that the International Card can be used for al l domesti c
trans ac tions and transactions i nvolving foreign exchange permitted under the
Forei gn Exchange Management Act and the Rul es framed there under by
Reserve Bank of India from time to ti me. I undertak e to use the card in strict
com pli ance with the appli cable Exchange Control/Managem ent Regulations and
any violat ion thereof will result in cancell ati on of the card and make me liabl e
under rel evant provision of the Act/Regul ati ons. I al so undertake to furni sh all the
details in res pect of any transaction entered into by me to facilitate any
investigation.
I hereby authori ze you to recover from my account the cost of the car d and all
ot her fees whi ch may be payabl e by SBI to MasterCard (other than transaction
fee) for extra-or dinary services rendered by them (example lost/stolen card).

Place

Date

Name

(Sig nature of Applicant)

Address :
Tel. No.:
Mobile :

e-mail

OFFICE USE
Acc ount partic ulars & s ignature of Applican t & mode of operation
verified. Request for issue of International Debit Card appro ved/dec lin ed
for t he reason
(delete as applicable)
Date

Aut horis ed official

Data for is sue of international Deb it Card forwarded for processing

Branc h Name
Code Number
Da te

Authorised official

Call Centre Details

Call us Toll free* : 1 600 - 112211

From other than MTNL / BSNL lines in India & abroad

at 00-91-80-2560 8470, 2560 8980
Als o pleas e co ntac t the nearest card iss uing bran ch or email us at :
sb ica shplus @v snl.net