Gold Debit Card Application Form: Add-On-Card (Individual) Customer Details Name

(First name) (Middle Name) (Last Name)

Customer Relationship Number Primary Account Number Details of the Add-On-Card Applicant Name
(First name) (Middle Name) (Last Name)

Gold Debit Card I would like to apply for Photo Card : Yes No

If yes, please provide latest passport size colour Photograph of Add-On Card Applicant*

Short Name (This name will appear on the Gold Debit Card) Date of Birth Mothers Maiden Name

Paste your latest Photograph here

(Please do not sign across the photograph)

Address

City

Pin

Telephone Daily ATM Limit (Rs.)_________________________________ Declaration

Mobile Daily POS Limit (Rs.)___________________________________

I have read, understood, accept and agree to be bound by the terms and conditions relating to the Debit Card and the Add-On Card issued by the Bank, including as may be amended from time to time by the Bank and available at www.kotak.com. I confirm that the Add-On Cardholder may avail of all the facilities (upto specific limits set by me which shall not be more than the available limit of my card). I also agree that the Add-On Cardholder will have access to all the accounts linked to my card. I hereby authorize the Bank to debit my account towards Rs ________ + Service Tax as applicable or charges incurred by the Add-On Card will be deemed as charges incurred by me and I will be fully liable for discharge of all obligations in respect of all the transactions performed by the Add-On Cardholder. I agree to pay the Bank any damages and compensation including direct and indirect damage, expenses that may be caused, incurred by the Bank arising out of any acts/omissions on the part of the AddOn Cardholder. I further declare that the said use of Gold Debit Card is compliant with all the applicable laws and regulations.

Customer Signature
1. You may apply for more than one Add-On card, by filling separate forms. 2. Add-On Card will be sent to customers mailing address as registered with the Bank. *In case no photo is submitted, non photo Gold Debit Card will be issued. Notes :

Date

For Bank Use Only Photo received: Branch Tracking reference number Signature verified by
KMB/GDCAF-A-I/P/04-07/V1.0

Yes ________________________/ No __________________ Customer Relationship Number Created by Authorised by