The Varachha Co-Op. Bank Ltd.

, Surat
Head Office: Affil Tower, L. H. Road, Surat.
Ph.: 0261-4008000 Fax: 0261-2558209 Email: info@varachhabank.com

APPLICATION FORM OF PASSWORD RESET

The Branch Manager Date: ____/____/_____

______________________Branch

Dear Sir, Old Application No.

I have forgotten my Account Alerts on Android Phone/Internet password or User ID. You are requested to
reset my Password or User ID and allot me new user or password as per my request. My User ID’s details given
below:

Please tick [  ] in appropriate box.

.Account Alerts on Android Phone ..Account Alerts on Internet
Customer ID: Customer ID:

I Forgot my User ID

I Forgot My Password I Forgot my User ID

My Password is locked My Password is locked

Change My New Mobile / Number I Forgot my Password

Please fill the entire form in CAPITAL LETTER.

NAME*

OLD MOBILE NO.*

E-Mail*

Sr. Joint Holder Detail

No Account Number
Joint Holder Name Joint Holder Sign.

Declaration and Acceptance

I confirm and undertake that I have read and understood the Terms and Conditions earlier
for usage of Account Alerts on Android Phone/Internet of The Varachha Co-Op. Bank Ltd. Signature of applicant

For Office Use Only

We confirm that the Details of account is KYC compliance, the address and Signatures of the account holder/holders given above is
entered correctly in CBS System.

Request accepted / Declined for the Reason ________________________________________________________________________________.

Authorized by Date : / / Branch Manager’s Signature & Branch Stamp