APPLICATION FOR CREDIT CARD

I wish to apply for ı Gold ı Classic Credit Card
INSTRUCTIONS TO FILL UP THE APPLICATION FORM
1 Fill all columns with requisite details in CAPITAL LETTERS.
2. Proof of annual income and PAN Card copy is mandatory.
3. Please sign in full in the space provided and on the 2nd page of the application form.
4.Terms and conditions and card member agreement are available at Indian bank Branches and on
the website www.indianbank.in which may be referred before applying for the card.
Please sign here in black ink

Please paste
your recent
passport size
color photograph
here
PERSONAL INFORMATION
Name: Mr./Mrs./Ms./Dr./Prof.
First Name Middle Name Last name
Name to be embossed on card (max of 20 characters)
Date of birth: ıı ıı ıııı Sex: ı M ı F Nationality
Legal Status: ı Resident ı NRI ı PIO Marital Status:ı Single ı Married No. of Dependents: ıı
PAN No ıııııııııı Passport No Place of Issue ….…………………………
Voter’s IDııııııııı Driving License No. Place of Issue…………………
Your Vehicle: ı 2-wheeler ı 4-wheeler ı None Vehicle Make ……………... Regn No
Mother’s Maiden Name: .
RESIDENCE
Current Residential Address:
City State
Pin Tel no.(with STD code) Mobile no
Personal Email ID …………………………………………... Land Mark ……………………………………………..
Permanent Residential Address:
City/State Pin
Tel no.(with STD code) Mobile no
Personal Email ID …………………………………………... Land Mark …………………………………………..
EMPLOYMENT Current DETAILS
residence is
ı Owned
ı Family
Owned
ı Rented
ı Company
leased
Period of stay:
…………
Months
Living with:
ı Parents
ı Spouse
ı Children
ı Alone
ı Others
Occupation:
ı Salaried
Whether Confirmed
ıYes ı No
ı Professional / Self-
Employed Details :
…………………. ….
ı Retired ı Student
ı Housewife
If Salaried,
employed with:
ı PSU/Govt
ı Public ltd
ı Private ltd
ı Partnership
ı Proprietorship
Industry details :
ı Aviation/Hospitality ı IT/Telecom
ı Banking/Financeı Travel/Tourism
ıMfg/Engg ı Entertainment/Media
ı Real Estate/Construction
ıOthers (please specify) …………
……………… ………………………...
Company/Employer Name : ………………………………….…………………………………….…………………………..
Employee (Applicant’s) Designation……………………………. Emp. No./ID / SR No………………………………………..
Office Address: ……………………………………………………………………………………………………………………
City/State.……………………….. Pin……………….. Official Email ID.………………………………………………………
Tel no. (with STD code) ………………………… Fax ……………………..……… Mobile ……………………………
FINANCIAL INFORMATION
Gross Annual Income (Rs): ııııııı ııı Name of your Banker: …………………………
Account Type: ı Savings ı Current Account No………………….. Branch:…………………………………………..
Account held for: ………………………. months
Additional Annual Income , if any (Rs): ……………………… and Source:…………………………………………..
DETAILS OF CREDIT CARDS HELD
SNO ISSUING BANK/INSTITUTIONS CARD NO CREDIT LIMIT (RS)
1 ……………………….. ıııı ıııı ıııı ıııı ııııııııı
2. ….. …………………….. ıııı ıııı ıııı ıııı ııııııııı
BILLING INSTRUCTIONS
Mail my billing statements to ı Current Residential Address ı Official Address
Do you want automatic debit on your Indian Bank A/c? ( for Indian Bank Customers only) ı Yes ı No
If yes, A/c type: ı Savings ı Current Branch: …………………………… Account No. ……………………….
Amount to be debited: ı Full amount due ı Minimum amount due ı ECS Debit*
* A copy of the cheque leaf / cancelled cheque leaf issued by the existing bank to be enclosed.
Place ______________ Date:___________ Signature of Applicant
____________________________________________________________________________________________________
RECOMMENDATION BY BRANCH : IBGA CODE :
1. KYC requirements have been fulfilled. 2. Recommended for issue of Credit Card
3. Value of connections:
Customer Identification No.CIF:
Branch :______________________ Date:___________
DOCUMENTS ATTACHED
Copies of: ı Statement of Accounts for last 3 months (other than Indian Bank) ı IT Proof/Latest Pay Slip
ı PAN Card*** ıAge Proof ı Passport ı Driving License ı Voter’s ID
DECLARATION
Assignment clause for insurance cover: I, …………………………………………………..do hereby assign the money
payable in the event of my death by the United India Insurance Co. Ltd., to (Name)………………………………..(relation to the
insured)………………and I further declare that his/her receipt shall be sufficient discharge to the Company.
I hereby declare that I has personally read and understood the terms and conditions governing the issue and usage of
the credit card. I verify that the contents stated in the above application are true to the best of my knowledge. I
hereby authorize the Bank and/or its associates to verify any information provided in this application form at any
given time. I also confirm that I shall promptly inform the Bank of any change in the information mentioned above.
The Bank may further use the said information for marketing, administrative and for other value addition purposes.
I agree that the Card will be issued to me upon the prevailing Terms and Conditions (which are subject to change
from time to time) of the Card Member Agreement. I, as the applicant of the Primary Card, shall be liable for all
charges incurred on the Primary Card and all Additional Cards on my account. For any enhancement of credit limit ,
I shall undertake to specifically apply for banks consideration.
Branch Manager’s
signature
Name Specimen
signature No.