This document is an application form for a "Centcash Debit Card" from Central Bank of India. It requests personal information from the applicant such as name, date of birth, contact details, account information. The applicant declares the information is correct and agrees to the terms and conditions governing usage of the debit card. The branch manager approves the application and the debit card number is issued upon entering the data into the card generation system.

1. APPLICATION FORM FOR “CENTCASH DEBIT CARD”
CENTRAL BANK OF INDIA For Branch Use: -
BRANCH: ________________
PERSONAL PARTICULARS
1. Name: Mr./Mrs./Ms. :
(Surname) (First Name) (Middle Name)
(Not more than 19 letters)
3. Father/Husband Name :
4. Date of Birth : 5. Gender : Male Female
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 Type
*
A/c No. Title of A/c
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
(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
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Data entered in Card Generation Software, File No.___________ sent to ATM Switch Centre through FTP/E-mail.
Date:__________________
Officer
Application Sr.No.
Card No.
2. Name to be embossed on card:
I/We irrevocably authorize the Bank to issue a Centcash Debit Card
to above applicant
Name Signature
(i)
(ii)
(iii)