‘CARD DIVISION INWARD No, | Naveen Complex #14, MG Road Bangalore 560001. MASTER No. | | Phone Toll Free: 1800425 0018 Email: hocancard@canarabank.com Web: http://wwwzcanarabank.com, CANARA CREDIT CARD APPLICATION lease use block otters /tck appropiate baxes / nite NA again ina INDIVIDUAL, pplcble items an do not leave any column blank APPLICATION FOR CANARA CREDIT Co a) VISACLASSIC c] MASTER CARD STANDARD ) MASTER CARD GOLD a) Domestic usage only b) Domestic & International usage Name to be embossed on the Card (Not to exceed 19 digi LSIB LAIN IAI [AIS |. its including spaces) Leave one box space between each name. Ss (Nf NAME IN FULL (CAPITAL LETTERS) SHANAVAS » SH DATE OF BIRTH: (DD/MM/YYYY) Jo- 04- 1945 sex. MaALE [St Femate L_| Marital Status le L_] Married [_] Father’s/Husband Name Sitatul WAMeep Educational Qualification, C+ A No. of Dependents A If Staff of Canara Bank, Staff No: Designation Branch / Office Details of Assets House-Own or rented : Vehicle : 4 wheeler details Vehicle : 2 wheeler details '~ Yes, Bullet- Any other: PIN Permanent. Address MEcHIZAYIL House, AWVANOAP PALLY PD, ADO. PATHAWANT HIT, KERALA Residential Address MECH ZAYIL House Anenioapraity Po Apoorw PATHANACTITTA, KERALA INDIE PIs GqI50F Offica / Businass Address INDE PIN 641525 PIN Telephone Number & Contact Details Residence ~ Landline No.OY9 34 ~2.9°9¢3€ | Office No. mobileNo. T4144 b1g06940 Fax no. tmailid_ Shanavas Sb Ogmai|s ComRs ea a aed PAN/GIR NUMBER: {Form No.60 to be enclosed in icu of PAN No.) Occupation: ‘Whether self employed: YES/NO Constitution: IF YES, enclose latest Balance Sheet Gross Annual / Net Income := pa. Liabilities if any © Card Limit Required : Income proof enclosed L) Form16 CO salary Certificate (duly signed by competent authority) (Latest Balance Sheet [51 rrassessment order / Latest 1T Return filed [anyother Document / Specify Bank Account Details Name ofthe Bank /Branch Customer ID Nature of Account AJcNo. Banking Since 1 Anladadanie AO Neo 246P1030 12.479 2009 2 GNORA Badle Apne Nos ZYSPlo4ol32¢3 2G EXISTING CARD DETAILS: Name of the Bank / Branch Expiry Date Issued by Ishall settle my CANARA CARD bill DIRECTLY [_] or By debit to my SB/CA/ OD / OCC A/eNo..... 234271040192 63 with, Branch of Canara Bank Conespondence / Bills may be sent to office] Residence DY Please permit me Revolving Payment facility, wherein | 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 Ren Signature of th€ Applicant request you to give add on card to the following family members. Name of the Family member Date of Birth Relationship ‘Signature of add-on cardholderCee Gthave verified all the details furnished in the application, verified originals of income proof/PAN and confirm that they are correct 7 The applicant is a customer of our Bank for the past. Years Cd We recommend issue of Canara Credit Card— with an overall ceiling limit off. CO We confirm that the income as declared by the applicant is correct Co Add-on cards may be issued We enclose copy of PAN Card, Passport size photograph, Passport (in case of NRI customers) & income proof duly verified by the Branch Name of the Branch Manager: Signature of the Branch Manager (with seal) 5.P.Nos Z Date: Name of the Branch: ..-.-.----..22.--- D.P. CODE: Seen ee eee ‘FORTHE USE OF CARD DIVISION / CIRCLE / BRANCH Limit Permitted / Recommended: & - - Declined / Rejected for the reason: -- Permitted / Recommended Reviewed Officer ‘Manager / Sr. Manager Divisional Manager / Chief Manager AGM/DGM/GM, Iesued on Valid Upto Main Card No, ‘-on Card No | | ‘Add-on Card No. | | Adi-on Card No. | | Montana |Pee | hereby apply for issue of Canara Card — Visa/Mastercard and Ideclare that 1am a Resident / now-Resident indian and that all the particulars and information | have furnished above are trueand correct. agree to informthat Bank, the changes, ifany in theabove said fecis esand when they occur. \agreeto pay theannual fees and other cianges that may be fixed enhanced by the Bank om time totime.undertaketo settiein all the dues arising from my Canara Credit Card issued to me and add-on Card/s that ate issued/may be issued. lundertake to the Canara Credit Card strict yin accordance withthe Exchange Control Regulation anc understand that In the evert of my failure todo s0,1 would be liable for action under FEMA regulations and willalzo be debarced fom international Credit Card fclity attheinstanceofReserve Bankofindia ct Canara Bank, thereby authorize you to inform the details of my transactions including default of payment that may occur toanyot thecredit card issuers, otner Banks, financial institutions or anyother organization asthe Bank may deem fit without obtaining any further oralor written consent fromme. | also authorize Canara Bonk to entrust recovery of any dues under my Canara Credit Card Visa/Master Card owing tomy default, toany recovery agentt and expenses incurredin this regard shall be borne by me | understand that in terms of the Credit Information Companies (Regulation) Act, 2005 the Banks bound to pro relation tomy credit history /repaymentrecord o a Credit information company (specifically authorized by RB) information | authorize the Bank to exchange, share, part with all informaticn related to my details and transaction history to its Affiliates / banks / financial institutions / Credit Bureaus / agencies / participation in any telecammunication ot electronicnetworkas nay be required by law, customary practice, credit reporting, statistical analysis and credit scor ng, verification or risk management and shall nothold Canara Banklisb\cfor useor disclosure ofthis iniarmation. | authorize Canara bank to make use of the personal information provided by me at the time of application forthe card on aneed- ‘to-know basis to deliver betler service to the customers. The Bank may use and shave the information provided by me with its affiliates and thitd parties for providing services and any service related activities such as cellecting subscription fees for such services, and notifying or contacting the Customers regarding ary problern with or the expiration of such services, inthis regard it ‘may be necessary te disclose the customer Information to one or more agents and contractors of the Bank and their sub- contractors, but sueh agents, contractors and sub-contractors shal be required to use theinformation obtained fromthe Bankonly forthese purposes. | declare that | have read the terms and conditions governing Canara Credit Card and am agreeable te and bound by them. |agree and understand thst issuance of Credit Card isthe sole discretion of Canara Bank and tne Bank reserves the tight to reject my application without assigningany eason, Place “o> Ayaan, Uae Date |2 1 ‘Signeture of Applicant /Main card holder "ASSIGNMENT NOMINATION FOR CARDHOLDERINSURANCE (Baraces- S'T . do hereby assign thy mongy payable by the concemned Insurance Co ln the event of my death due to acidert tc. Shape biin..who em. aw tbe vis her signatures appended belo [he by author Canara Bank te adjust the Card Division Viza/Mostercard dues #f any from the insurance claims setted | further declare tat the nominee's ‘eceiptshallbesuiient prof ofdischange wo heconcerred Insuranceco, | am aware that the role of card Division under Cancare insurance would be purely to fecifate the payment of aremium on my. behalf as a compliment ard that the onus of making valid ciim with the Insurance Co lias on the nomnca/legel heir of he cardholder. Card Divison wll not have any rezponsiblty in Une mater of eitlement of teclaims or make any representation on aim processing withthe Insurance Company, nature of ipfligant/Cardholder Signatureofthe Nominee SPOUSEINSURANCEDETANS Ll syoounmnnsnnny (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 (Nameof the Norninee) & further declare that his/her receipt shall be sufficient discharge to the Company/fank. The Bank reserves the right to adjust the monies settled under the ciaim towards CanataCard dues, ifany, ofthe applicant/cardholder, Ca oath] 2245~ Signatureot applicant cardholder Signaturcofthe Spouse Signature of witness: Name fradcressofthewitness.au. a addayor,