Application form for issue of CANARA DEBIT CARD

(Please fill this form in Capital letters)

From: To:

______________________ Canara Bank

______________________ __________________ Branch
______________________ DP Code: _________

Date: ___________________

Please issue me a Canara Bank Debit Card as requested hereunder:

(Please tick (
) the appropriate boxes)

1  New  Additional  Replacement

2 (i)  RuPay  Visa  MasterCard

(ii)  Classic/Standard  Platinum  Business Debit Card
(iii)  Personalized  non-Personalized (does not bear name on the Card)
(iv)  for Domestic Use  for both Domestic & International Use (Global)

Date of Birth:

PAN Number :

Mobile Number:

Name as required on the Canara Debit Card (Not to exceed 19 characters including spaces):

Account Number to which Canara Debit Card is to be linked:

(Primary A/c)
SB / CA / OD :

SB / CA / OD :

SB / CA / OD :

SB / CA / OD :

P.S.: In case of Joint Accounts, Operation Condition should be “SEVERALLY”.

p.t.o.
 -2–

I/We am/are aware that the rules for the issuance and usage of Canara Bank Debit Card
are governed by Terms & Conditions set out therein. I/We accept to be bound by such
Terms & Conditions unconditionally and to any changes made therein from time to time
by accepting / signing on the reverse of the Canara Bank Debit Card / using the card.
I/We undertake that the usage is strictly in accordance with the exchange control
Regulations / other RBI guidelines issued from time to time and in the event of any
failure to do so I/We am/are aware that I/We am/are liable for action under FEMA 1999.
I/We understand that upon issue of Canara Bank Debit Card to me, the existing Canara
Bank Debit Card / ATM Card, if availed will be deactivated.

Thanking you,

Yours faithfully,

(SIGNATURE OF THE ACCOUNT HOLDER)

FOR OFFICE USE

Branch Confirmation:

We confirm as follows:

1) Signature of the customer and mode of operation of the account(s) verified.

2) Customer satisfies the eligibility conditions for issuance of Canara Debit Card.
3) Authorized to issue the Canara Debit Card.

Debit Card Issued Details:

) the appropriate boxes:

Please tick (

1  New  Additional  Replacement
 RuPay  Visa  MasterCard
2  Classic/Standard  Platinum  Business Debit Card
 Personalized  non-Personalized
 for Domestic Use  for both Domestic & International Use (Global)

Checked / Verified by

Date: Authorized Signatory