CARD DIVISION

P.B. No. 5073, Naveen Complex, 14, M.G. Road, Bangalore - 560 001.
Phone PBX : 080 - 25584040 Extn.: 289 / 249 Direct : 080 - 25584172
Email : hocancard@canbank.co.in web http://www.canarabank.com

INWARD No.
MASTER No.

CANARA BANK GLOBAL CREDIT CARD APPLICATION

INDIVIDUAL

Please use block Letters/ tick appropriate boxes / write NA against inapplicable items and do not leave any column blank.

APPLICATION FOR CANARA CARD GLOBAL -

a) VISA CLASSIC

c) MASTER CARD STANDARD

b) VISA GOLD

d) MASTER CARD GOLD

Name to be embossed on the Card (Not to exceed 19 digits including spaces) Leave one box space between each name.

NAME IN FULL (CAPITAL LETTERS)

DATE OF BIRTH : (DD/MM/YYYY)
SEX : MALE

Marital Status

FEMALE

Single

Married

Father's/Husband Name
Educational Qualification :

No. of Dependents
Designation

If Staff of Canara Bank, Staff No :

Details of Assets

Branch / Office

Residential Address

House - Own or rented :

Vehicle : 4 wheeler details
Vehicle : 2 wheeler details :
Any other :

PIN

Permanent Address

Office / Business Address

PIN

PIN

Telephone Number & Contact Details

Residence - Landline No.

Office No.

Mobile No.

Fax No.

E-mail ID
OCCUPATION & FINANCIAL DETAILS
PAN/GIR number :
(Form No. 60 to be enclosed in lieu of PAN No.)
Occupation :
Whether self employed : YES / NO
If YES, enclose latest Balance Sheet
Gross Annual / Net Income : Rs.
p.a.
Income proof enclosed
Form 16
Latest Balance Sheet
Any other Document / Specify
Bank Account Details
Name of the Bank / Branch
1
2

Constitution :
Liabilities if any Rs.

Salary Certificate (duly signed by competent authority)

IT Assessment Order / Latest IT Return filed

Customer ID

Nature of Account

EXISTING CARD DETAILS :

Name of the Bank / Branch
1
2

A/c No.

Expiry date

Banking Since

Issued by

MODE OF SETTLEMENT
I shall settle my CANARA CARD bill DIRECTY

or

By debit to my SB / CA / OD / OCC A/c No.....................................................................

with................................................................................................. Branch of Canara Bank
Correspondence / Bills may be sent to

Office

Residence

Please permit me Revolving Payment facility, wherein I will be required to pay 5% of the billed amount every month
with the carried over balance attracting interest at rates as applicable from time to time
Signature of the Applicant

I request you to give add on card to the following family members.

Name of the Family member

Date of Birth

Relationship

1. -----------------------------------------------------

-----------------------------------------------------

2.-----------------------------------------------------

-----------------------------------------------------

Signature of add-on cardholder NO.1

--------------------------------------------------------------------Signature of add-on cardholder No.2

DECLARATION
I hereby apply for issue of CANARA CARD GLOBAL- VISA/MASTER CARD and declare that I am a Resident /Non -Resident Indian and that all the particulars and
information I have furnished above are true and correct. I agree to inform the Bank, the changes, if any in the above said facts as and when they occur.
I agree to pay the Annual fees and other charges that may be fixed/enhanced by the Bank from time to time. I undertake to settle in full all the dues arising
from my Cancard issued to me and Add-On card/s that are issued/may be issued. I undertake to utilize the Canara Bank Global Card strictly in accordance
with the Exchange control Regulations & understand that in the event of my failure to do so, I would be liable for action under FEMA 1999 and will also be
debarred from International Credit Card facility at the instance of Reserve Bank of India or Canara Bank.
I hereby authorise you to inform the details of my transactions including default of -payment that may occur, to any of the Credit Card issuers, other Banks,
Financial Institutions or any other organisation as the Bank may deem fit without obtaining any further oral or written consent from me. I also authorise
Canara Bank to entrust recovery of any dues under my Canara Card Global - Visa / Master Card owing to my default, to any recovery agent and expenses
incurred in this regard shall be borne by me.
I declare that I have read the terms and conditions governing Canara Card and am agreeable to and bound by them. I agree and understand that issuance of
Credit Card is the sole discretion of Canara Bank and the Bank reserves the right to reject my application without assigning any reason.
Place:
Date:

Signature of Applicant/ Main card holder

ASSIGNMENT / NOMINATION FOR CARDHOLDER INSURANCE

I..........................................................................................., do hereby assign the money payable by- the concerned Insurance Co in the event of my death due to
accident to....................................................who is my........................................His/her signature is appended below. I hereby authorise Canara Bank to adjust the Card
Division Global Visa/ MasterCard dues if any from the insurance claims settled. I further declare that the nominee's receipt shall be sufficient proof of
discharge to the concerned Insurance co.
I am aware that the role of Card Division under Cancare Insurance would be purely to facilitate the payment of premium on my behalf as a compliment and
that the onus of making valid claim with the Insurance Co. lies on the nominee/legal heir of the cardholder. Card Division will not have any responsibility in
the matter of settlement of the claims or make any representation on claim processing with the Insurance Company.
Signature of Applicant/Card holder

Signature of the Nominee

SPOUSE INSURANCE DETAILS

I......................................................................................, (name of the spouse of applicant) do hereby assign the money payable by the M/s. United India Insurance Co.,
Insurance Company in the event of my death to
(Name of the Nominee) & I further declare that his/her receipt shall be sufficient discharge to the
Company/Bank. The Bank reserves the right to adjust the monies settled under the claim towards Canara Card dues, if any, of the applicant/cardholder.
Date:

Signature of applicant / cardholder

Signature of the Spouse

Signature of witness:
Name & address of the witness------------------------------------------------------------------------------------------Dated this---------------------- day of------------------------ 20----------------

at ----------------------------------------------

BRANCH RECOMMENDATION
I have verified all the details furnished in the application and confirm that they are correct.
The applicant is a customer of our Bank for the past.......................... years.
We recommend issue of Canara Card - Global with an overall ceilling limit of Rs..............................
We confirm that the income as declared by the applicant is correct.
Add - on cards may be issued
Name of the Branch Manager :
S.P. No. :

Signature of Branch manager

(with seal)

Date :

Name of the Branch :

D.P. CODE :

FOR THE USE OF CARD DIVISION

Limit Permitted / Recommended : Rs.

Declined / Rejected for the reason :

Permitted / Recommended

Officer

Manager

Reviewed / Permitted

Divisional Manager

AGM/DGM/GM
Issued on

Main Card No.

Add - on Card No.
Add - on Card No.

Reviewed

Valid Upto