e-Banking Service Request [orm

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Branch (vnur)' Date (frfr):-

lAffe request you to provide us below mentioned services offered by your bank.
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! VtSl Card (ft-sr ore) [ Sa;ito e-Banking (rrtudr E-ttu-S) [ i-Banking (€ilE-ttu-g]

Applicant's Name (BLOCK LilTERS) IT-[rT-

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Applicant's address

Account number

A.
(frffir
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VISA CARD tfi-sr o.r€)
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Card Type: Ne1t, Reolacement Supplementary Reoin
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0ebit USD Debit USD Prepaid Sanima lnstant Card
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lnstant iFr€

[6r€ qftrarqr-o)
MIIIIIIII
To replace card o-rFrl

Current card Number (ETo-dr o-r€ q'*s):

Reason for replacement (chtem-r-o'r orqq):

For supplementa '

Name:

ITTI:

B. Sajilo e-BANKING (nfti-d E-ttu-q)

Mobile Number (ffio =i):

Application for: New Delete Number change Add Account Add Mob, No
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Modification Add Repin

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Changed/Add Mobile No. (qRrtu/erq ffio t):

New Account Number (=dr qrdr "i.): [I-t-T- riTl]-]
Required Service: Sanima Mobile Banking Sanima Premium Banking
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C. i-BANKING ( snq-ttuV.)

Email(sto):

Service Required (ur+r+o Q-o)

a. View 0nly:

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b. Fund lransfer:
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Account to be linked (qR qror .rjcf ,Tlqrt
S.No (o.e.) Account Number (uror ;i) Aceount Holde/s Name (unreroro'r mr)

Please supply me the following user lD. lf suggested user lD of my choice has already been used, l/We accept the user lD assigned by
the bank on its own discretion. (User lD should be of 2 to 6 characters.)

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Please debit my/our account no, maintained with you for applicable fees for the
services.

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Authotrized Signature & Stamp:

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l/We acknowledge the receipt of Card Pin/l-Banking facility under e-banking services.

Card I PIN n i-Banking E

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Authotrized Signature & Stamp: Date:

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For Bank Use only: (ffir nffir ffi qra)

Ref No.:(tm q)

Enteredby:(tcr r{) Approved by:(ffiqd r{)

,€'u,SanimaBank

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