Credit Card Application Form

(Please Complete in The Block Letters)

Account Name MD. SEFAT-UL ISLAM

Card Number

PMO/RO 1230902629 RM 1180601596

Branch Code 0010 Branch Name Dhanmondi

Runner Code Proposal ID 202403000323

CIF ID 0287898 Application Date 09 March, 2024

Organization RAFI TEXMODE LTD. Designation DIRECTOR

Application Type General

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 Credit Card Application Form
(Please Complete in The Block Letters)
Application Date :
09 March, 2024

Application Details
Dear Sir, I hereby apply for a LankaBangla - 1. MC TITANIUM CREDIT - Request Limit(200000.00) - Approve Limit(200000.00)
Card Check Option : Yes No, Proposal Id: 202403000323, CIF ID: 0287898

Personal Details
Mr. Ms. Mrs. Others (Please Specify)
Applicant's Full Name (English) MD. SEFAT-UL ISLAM

Applicant's Full Name (Bengali)

(To be elaborated in case of abbreviated name)

Date of Birth 31/12/1993 Nationality Bangladeshi If Non-Bangladeshi Visa No Expiry Date

Passport No (If available) Expiry Date NID/Smart card No. 19937615517000398

Marital Status Single Married Others Spouse Name (English) AMENA SULTANA

Spouse Contact No. 01713699444 No. of Dependents - - - - - Spouse Name (Bengali)

Is Spouse Employed? Yes No Spouse Organization Name, Designation & Address:

Tin/e-Tin No. 724357128500

Educational Qualification Graduate Post Graduate Others (Please Specify)

Father's Name (English) MD ABDUL MATIN Father's Name (Bengali) (A
security feature for your protection)

Mother's Name (English) AFROZA YESMIN Mother's Name (Bengali) (A

security feature for your protection)

Card Embossing Name MD. SEFAT-UL ISLAM

Contact Details
Your Residential Status Owned Family Owned Rented Company Provided Others (Please Specify)
Residential Address VILA-SHARMIN,34 WEST MONIPUR,MIRPUR-2, DHAKA-1216

Road No: House No: Floor No: Flat No:

Block/Lane/Section/Sector/Line/Avenue No: Nearest Landmark:

City MIRPUR Post Code 1216 Residence Phone Mobile 01711991926

Email SEFAT@COTTEXWORLD.COM

Duration of stay in current address 4 Years 0 Months

Your Permanent Address VILL-BHARARA,,PO-DOGACHI,PABNA SADAR, PABNA, PABNA

Professional Information
Your are Services Business Student Retired Others (Please Specify)
Name of Organization RAFI TEXMODE LTD. Year of incorporation (If self employed)

Department Designation DIRECTOR

Office Address SKYLARK POINT (9th fl) 175, SHAHID SYED NAZRUL ISLAM SHARANI BIJOYNAGAR DHAKA

Road No: House No: Floor No: Flat No:

Block/Lane/Section/Sector/Line/Avenue No: Nearest Landmark:

Office Phone E-mail SEFAT@COTTEXWORLD.COM

City Post Code 1000 Experience with current orgnization 3 years 4 months

Name of previous
Joining Date 2020-12-02 Total Experience 4 _ Years _ 0 _ Months
organization

Information of Income
Salaried Basic (Monthly) TK. Allowances (Monthly) TK Total Monthly Salary Tk.

Self-employed Gross Income TK Expenses TK. Net Income Tk

Source of Others Income Income of Spouse TK. Others Tk.

Additional Income

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 Correspondent Address (Select One)
th th th th th th
Office Address Residence Address Bill Statement Date 5 10 15 20 25 30

About Your Bank Accounts

Bank Name & Branch Account No. A/C Type

Details of Others Credit Card(s) and Loan(s) (Please use separate sheet if required)

Social Living Standard

References (Service Holder/Business Person/Self Employed)

1. Name of The Reference( BLOCK-E,AVENUE
MD ASDUZZAMAN Present Address
Resident in Bangladesh) 1/71,SECTION12,MIPUR,DHAKA

Working Addres BLOCK-E,AVENUE 1/71,SECTION12,MIPUR,DHAKA Company Name ZARA CORPORATION

Designation CHIEF COMMERCIAL OFFICER Phone No. (Res.)

Mobile 01764141432 Email

Relationship with Applicant Brother

2. Name of The Reference(

MD MEHDI BILLAH Present Address 11/A,MIRBAGH,MOGHBAZAR,DHAKA
Resident in Bangladesh)

175 SHAHID SYED NAZRUL ISLAM

Working Addres Company Name COTTEX INC
SHARANI,,BIJOYNOGOR,DHAKA

Designation GM Phone No. (Res.)

Mobile 01953639297 Email

Relationship with Applicant Friend

Information of Supplimentary Card Applicant.

No Supplimentary Card Details Available

Photograph Supplementary Card Applicant Declaration

Supplementary Card
Applicant
I/We, the Supplementary Card applicant(s) agree, to be jointly and severally liable for all
Please attach a recent
transactions processed and repayment against the transaction by the use of the Card(s)
color passport size
applied for and issued by LankaBangla Finance to the Primary Card applicant and/or
Photograph in this box,
myself (ourselves), and to be bound by all the Terms and Conditions of the LankaBangla
write your name on the
Credit Card agreement which accompanies the Card.
back of the photograph
Primary (Please do not staple)
Applicant

Signatures
Date _ _ _ _ _ _ _ _ _ _ _
Primary Card Applicant's Signature Supplementa ry Card Applicant's Signature

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