SRF-1

dsoy cSad ds mi;ksx ds fy;s%

FOR BANK USE ONLY:
xzkgd vkbZ-Mh Customer ID.

lsok vuqjks/k QkeZ Service Request Form

[kkrk la[;k
Account No.
xzkgd dk uke% Name of Customer:
'kh"kZd Title igyk uke First Name e/; uke Middle Name vafre uke Last Name

eSa@ge fuEu  fVd dh gqbZ lsokvksa ds fy, vkosnu djrk gw¡@djrs gSa
I/we apply for the following  tick marked services

1- irs eas ifjorZu% Change of Address:

i=kpkj@LFkkuh;@fuokl irk LFkk;h irk dk;kZy; irk
Communication/Local/Residence Address Permanent Address Office Address

uxj/ftyk City/District jkT; State

fiu Pin Qksu ua Phone No. eksckby ua Mobile No.
bZ-esy vbZ Mh E-Mail ID

2- laidZ C;kSjk es ifjorZu% Change of Contact Details:

bZesy vkbMh eksckby uEcj
Email ID Mobile Number

3- igpku C;kSjk v|ru% Update Identity Details:

O;olk; dwV
Occupation _________________ Code
iSu dkMZ tUe fnukad vk/kkj dkMZ ua vk/kkj lhfMax pkfg,
PAN Card Date of Birth Aadhar Card No. Aadhar Seeding Required

ikliksVZ lekfIr fnukad Mªkbfoax ykblsal lekfIr fnukad

Passport Expiry Date Driving Licence Expiry Date

4- izek.ki=@fooj.k tkjh djuk% Issuance Certificates / Statements*:

'ks"k izek.ki= o;k fuEu psd ds fy, psd Hkqxrku izek.ki=
Balance Certificate as on Cheque paid Certificate for Cheque No
VhMh,l izek.ki= C;kt izek.ki= [kkrksa ds fooj.k MqIyhdsV ikl cqd cSadj dk tkap izek.ki= ds fy,
TDS Certificate Interest Certificate Statement of Accounts Duplicate Pass Book Banker's verification Certificate for
vof/k ls rd gLrk{kj QksVks irk
For the Period to Signature Photo Address

5- oSdfYid pSuYl% Alternate Channels:

,Vh,e@MsfcV dkMZ ,Vh,e fiu ,l,e,l vyVZl~ bZ&fooj.k
ATM/Debit Card ATM Pin SMS Alerts e-statement
MwIyhdsV ,Vh,e@MsfcV dkMZ iqjkuk dkMZ ua # ,l-vkj- ua #
Duplicate ATM/Debit Card Old Card No.# S.R. No.#
jsfM dhV MsfcV dkMZ Ready Kit Debit Card oS;fDrd izkFkfed dkMZ Personalised Primary Card* oS;fDrd ,M vkWWu dkMZ Personalised Add-on Card*

dkMZ uΠCard No. dkMZ ij uke Name on Card dkMZ ij uke Name on Card

6- psd cqd ekax% Cheque Book Requisition*:

—i;k 20 i™kks dh cpr cSad psd cqd@cqds tkjh djas —i;k 50@100 i™kks dh pkyw tek psd cqd@cqds tkjh djas
Please Issue SB Cheque Book/s with 20 leaves each Please Issue CD Cheque Book/s with 50/100 leaves each

7- LFkk;h vuqns'k% Standing Instructions:

varj.k esjs@gekjs mi;ZqDr cpr@lap;h@_.k [kkrs ls
Transfer ` from the above mentioned account to my/our SB/Cumulative/Loan account numbered
i{k es izR;sd ekg@frekgh
favouring every month/quarter
ls
on from
esjk ;wfu;u cSad ØsfMV dkMZ dks ekfld ns;ksa ds fy, mi;qDr [kkrs ls fyad djsa
Link my Union Bank Credit Card to the above mentioned account for monthly dues
* eSa@ge bl ckr ds fy, lger gS fd izek.ki=@fooj.k@dkMZ@psd cqd@cqds
'kk[kk ls izkIr dh tk,axh esjs@gekjs i=kpkj irs ij izsf"kr fd;k tk,xk
* I/we agree that the Certificates/ Statements/ Card/ Cheque Book/s will be Collected from the Branch Dispatched to my/our communication Address
# dsoy MwIyhdsV ,Vh,e@MsfcV dkMZ vuqjks/k # Applicable for duplicate ATM/Debit Card requests only
8- uke tksMuk@gVkuk@lq/kkj% Addition / Deletion / Modification of Name:
uke@ukekas dks tkM
s us ds fy, xzkgd vkbZ-Mh Customer ID. xzkgd vkbZ-Mh Customer ID.
Addition of Name/s

mikf/k Title izFke uke First Name e/; uke Middle Name vafre uke Last Name

uke@ukekas dks gVkus ds fy, xzkgd vkbZ-Mh Customer ID. xzkgd vkbZ-Mh Customer ID.
Deletion of Name/s

mikf/k Title izFke uke First Name e/; uke Middle Name vafre uke Last Name

ukekas es l/qkkj ds fy, xzkgd vkbZ-Mh Customer ID. xzkgd vkbZ-Mh Customer ID.
Modification of Name/s

mikf/k Title izFke uke First Name e/; uke Middle Name vafre uke Last Name

9- Hkqxrku jksduk% Stop Payment:

pSd@pSdksa dk Hkqxrku jksds ls fnukad rd `
Stop Payment of Cheque/s from to Dated for
ikl esa eSllZ@Jh@Jhefr
Favouring M/s/ Mr/ Mrs
dkj.k
Reason

10- fMekaM Mªk¶V@is vkMZj dk fujLrhdj.k% Cancellation of Demand Draft/Pay Order:

—i;k ly
a Xu fMekM
a M¶ªV@is vkMjZ dks fujLr djas fnukd
a
Please cancel the enclosed original Demand Draft/Pay order No dated
e@
s Jh@lJ
q h ds i{k eas
for ` favouring M/s /Mr/Mrs
vkSj bldh jkf'k esjs@gekjs mi;qZDr [kkrs esa tek djsa and credit the proceeds to my/our above mentioned account
11- [kkrs dh fLFkfr esa ifjorZu% Change of A/c Status:
U;wure csysUl ds lkFk cpr@pkyw cSad lkekU; ls cpr@pkyw cSad ¶ysDlh vof/k ekg
SB/CD General to SB/CD Flexi with Minimum Balance for a Period of months
pkyw tek lkekU; ls ;wlhlh, U;w MksjesaV ls lfØ; ch,lchfM, ls lkekU; vo;Ld ls o;Ld ukekadu esa ifjorZu
CD General to UCCA New Dormant to Active BSBDA to General Minor to Major Change of Nomination

12- [kkrksa dk varj.k@can djuk% Transfer / Closure of A/c:

gk¡] eSa@ge [kkrk varj.k djus ds fy, vkosnu djuk pkgrk gw¡@pkgrs gSa 'kk[kk lksy vkbZMh
Yes, I/we wish to apply for transfer of the account to Branch Sol ID
gk¡] eSa@ge [kkrk can djus ds fy, vkosnu djuk pkgrk gw¡@pkgrs gSa
Yes, I/we wish to apply for closure of the account

13- ?kks"k.kk% Declaration:

eSa@ge vkils mDr lsok,a iznku djus vkSj bu ij yxus okys lsokizHkkjksa ds fy,] ;fn dksbZ gks] vFkok le;≤ ij ykxw dks esjs@gekjs [kkrksa esa MsfcV djus
dk vuqjks/k djrk gw¡- tgka Hkh ykxw gSa] ogka mi;Dr nLrkost layXu dj fn, x, gSa- eSa@ge ,d ckj fQj vkLoLr djrs gSa fd eSa@ge [kkrk [kksyrs le; dh
xbZ ?kks"k.kk@opu dk vuqikyu djsaxs-
I/We request you to facilitate the above services and debit my/our account for service charges if any or as applicable from time to time.
Relevant documents wherever applicable have been enclosed. I/we once again assure you that I/we will abide by the declaration/undertaking
given at the time of account opening.

vkosnd1 dk uke vkosnd2 dk uke vkosnd3 dk uke

Name of Applicant1 Name of Applicant2 Name of Applicant3

gLrk{kj vkosnd1 gLrk{kj vkosnd2 gLrk{kj vkosnd3

Signature of Applicant1 Signature of Applicant2 Signature of Applicant3

LFkku% fnukad%
Place: Date:

dsoy cSad ds mi;ksx ds fy, For Bank Use Only

eSa@ge ,r}kjk ?kksf"kr djrs gSa fd QkeZ ,oa mi;qDr nLrkost izkIr ,oa lR;kfir dj fy, x, gSa-
I/We hereby declare that the form and relevant documents have been obtained and verified.

LFkku% fnukad% vkjih@ih, uEcj ds lkFk izkf/k—r gLrk{kj

Place: Date: Authorized Signature with RP / PA No.

ver 2017