APPLICATION FORM FOR “CENTCASH DEBIT CARD”

CENTRAL BANK OF INDIA For Branch Use: -

Application
Sr.No.
Card No.

BRANCH: ________________

PERSONAL PARTICULARS

1. Name: Mr./Mrs./Ms.
:
(Surname) (First Name) (Middle Name)

2. Name to be embossed on (Not more than 19

card: letters)

3. Father/Husband Name
:

4. Date of Birth 5. Gender : Mal Femal

: e e
DD / MM / YYYY

6. Details of existing cards Name of Bank Type of Card Card No.

:
i
ii

7. Mailing Address
:

PIN

8. Permanent Address
:

PIN

9. Phone No. Residence Office Mobile

:
10.E-mail

ACCOUNT PARTICULARS

Branch A/c A/c No. Title of A/c

Type *
Primary A/c
Secondary A/c
(i)
(
ii)
(
iii)
* (Type: SB/CD/OD)

Declaration:

I declare that above information is correct. I request Central Bank of India to issue a Centcash Debit
Card to me. I have read and understood the terms and conditions governing the usage of centcash
debit card. I accept to be bound by the said terms & conditions or to any changes made therein from
time to time by the bank at its sole discretion without any notice to me.. I unconditionally and
irrevocably authorize the Bank to debit my account with an amount equivalent to the fees and
charges for use of my Centcash Debit Card.
I, without prejudice to the above, accept Banks lien on all my deposits, present and future, held in
the Primary A/c as well as any other Deposit account/s.

I understand that upon issuance of Centcash Debit Card, my previous ATM card of Central Bank of
India will be deactivated.
I undertake that the utilization of the Centcash Debit Card would be strictly in accordance with the
Exchange Control Regulations and in the event of any failure to do so I am aware that I am liable for
action under Foreign Exchange Management Act (FEMA) 1999.
I undertake to fulfill and abide by all guidelines issued by Central Bank of India from time to time
regarding the International use of Centcash Debit Card and foreign currency transactions.

Date:
Applicant’s Signature
I/We irrevocably authorize the Bank to issue a Centcash Debit
Card to above applicant
Name Signature
(i)
(ii)
(iii)
(In case of joint/firm account, application form must be signed by
all the joint account holders/partners)

For Branch use only:

- The primary account of the customer is conducted satisfactory and we confirm having
verified the above particulars/signatures.
- We also confirm having verified the above particulars / signatures / proof of having
secondary accounts / and authority to operate these accounts got verified from the concerned
branch.
- The applicant is eligible for issuance of Centcash Debit Card.
Approved for issuance of Centcash Debit Card.

Date:__________________
Branch Manager

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-----------------------

Data entered in Card Generation Software, File No.___________ sent to ATM Switch Centre
through FTP/E-mail.

Date:__________________
Officer