PI Banking Application Form

The Manager
Pubali Bank Limited
Laboratory Road Branch
Mirpur Road
Dhanmondi

I , Kushal Podder hereby submit the following information for availing of PI banking service with following rights.

Account Information : Customer ID : 16794280

I want to operate the following account(s) through PI Banking :

Account Number Transaction

SL. Account Title Signature(s)
(13 Digits) Right

1 1345101143565 KUSHAL PODDER Yes [ ] No [ ]

(Please enclose seperate sheet if more accounts to be linked)

* Note: All accounts must be under same Customer ID, Email and Mobile Number.

Name : KUSHAL PODDER

Father's Name : KANCHAN PODDER

Mother's Name : POLY PODDER

Spouse Name :

Mailing Address :

Date of Birth : 16-12-1998

Occupation : National ID : 5561355453

Office Phone : FAX :

Home Phone : Mobile No. : 01780013683

E-Mail : kpodder24@gmail.com
Please check your email again. Email address will be updated on both Core Banking System and PI Banking.
 Declaration of the Customer
I confirm that the above information is true and complete. I accept and agree to be bound by the terms and
conditions of using PI Banking Service and the rules governing customer accounts with Pubali Bank Limited. I
also accept and agree that I am liable for all charges incurred through the use of this facility. I hereby
indemnify the bank against all losses that may incur as a result of my use of the facility.

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Signature of the First Applicant Signature of the Joint Applicant (If any)
Date: ____/____/_______ Date: ____/____/_______

For branch use only

The above customer’s information and signature(s) are verified and found correct. The customer is registered.
We recommend for issuance of Login ID and Password for PI Banking.

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Authorized Signature Authorized Signature