NOM

,svks,Q Ø-
AOF No.

mikf/k

gkW ugh
Whether name of the nominee to be printed on Pass Book/Statement of Account/Deposit Receipt Yes No

irk Address

uxj/ftyk City/District jkT; State

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

Insurance (Death due to accident)

izkFkfed MsfcV dkMZ ds fy, ukfer O;fDr Nomination for Primary Debit Card

,Mvku-dkMZ ds fy, ukfer O;fDr Nomination for Add-on Debit Card

* * *
*Signature(s)/thumb Impression of Depositor(s) *Signature(s)/thumb Impression of Depositor(s) *Signature(s)/thumb Impression of Depositor(s)

lk{kh@;ksa ds uke Name of Witness/es

lk{kh 1 dk uke vkSj irk Name & Address of Witness 1 lk{kh 2 dk uke vkSj irk Name & Address of Witness 2

*vaxwBs dh Nki nks lkf{k;ks }kjk vuqizekf.kr dh tk, *Thumb impression(s) shall be attested by two Witnesses

Acknowledgment for Nomination

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&ds laca/k esa&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
¼[kkrs dk uke½ ¼tekjkf'k/kkjdksa ds uke½
ls ukekadu djus ds fy, ukekadu ds fy, ukekadu QkWeZ Øe- Mh, &1 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& dks izkIr gqvk-
Received on _________________________ nomination form DA-1 for making nomination from____________________________________________
__________________________________________________________________ in respect of______________________________________________.
(Name of deposit holder/s) (Name of the Account)
tekjkf'k [kkrk Ø- —rs ;wfu;uFor
cSadUnion
vkWQ Bank
bafM;kof India
Deposit Account No. For Union Bank of India
ukekadu iathdj.k Ø- izkf/k—r gLrk{kjdrkZ
Authorised Signatory
Nomination Registration No. Authorised Signatory
fnukad