DEBIT CARD ISSUANCE/RE-ISSUANCE FORM

Date : D D M M Y Y Y Y
ACCOUNT DETAILS
Citibank A/c No :
Account Type

Branch :
c Savings Account

c Current Account
(Please ll in details only for the holder making the request)

CARD HOLDER DETAILS

Please note: Debit cards are not issued to joint accounts with 'Joint' signature rule.

PRIMARY ACCOUNT HOLDER

Name

*Please paste your passport

(Name to be embossed on the card)

Reason for
Request
Photo Card
Required*

size colour photograph here,

c New Issuance

c Lost/Stolen

c Damaged

c Other ________________________

only if you would like a Photo-

c Expired

card. Do not use pins,

tape, staples to
afx the photograph.

c Yes c No

Existing Debit :
Card No.
ADDITIONAL ACCOUNT HOLDER
Name

*Please paste your passport

size colour photograph here,

(Name to be embossed on the card)

only if you would like a Photo-

Reason for
Request
Photo Card
Required*

c New Issuance

c Lost/Stolen

c Expired

c Damaged

c Other ___________________

card. Do not use pins,

tape, staples to

afx the photograph.

c Yes c No

Existing Debit :
Card No.
DECLARATION
I declare that the above information is correct. I have read the terms and conditions governing the operations of the debit card as part of the general terms
and conditions governing my accounts, and agree to be bound by the same, including:
a) The use of the Debit Card is subject to the minimum applicable credit balance available in the Account.
b) The use of the Debit Card shall stand automatically terminated in the event I cease to be an Account Holder(s) or my account is rendered temporarily or
permanently non-operational.
Further, I conrm that the attached photograph (if any) against my name, is the present true identity of myself, which I authorize Citibank, N.A., to apply to my
Debit Card and for which I accept full responsibility and agree not to make any claim against Citibank, N.A., in respect thereto. I agree to allow ` 200 to be
debited from my account per Photo Debit Card requested (if any), as per the applicable schedule of charges which is subject to change from time to time.

CUSTOMER SIGNATURE (To be signed as per signature rule for the account):

(Signature of First Holder)

(Signature of Additional Holder)

CV/BAN/DBRF/Ver1.5/06-14