fot;k cSad VIJAYA BANK

foHkkx % lwpuk o izks|ksfxdh

Dept : Information Technology
iz/kku dk;kZy; Head Office,
41/2, egkRek xka/kh jksM MG Road,
csaxywj BANGALORE - 560 001

¨¸ú-›¸½’ ¸ÿ¹ˆ¿ÅŠ¸ ‚¸¨¸½™›¸ œ¸€¸Ÿ¸Ä

V-NET BANKING APPLICATION FORM
(¨¡¸¹Æ÷¸¡¸¸½¿ ˆ½Å ¹¥¸‡ For Individuals)

¹™›¸¸¿ˆÅ Date / /
¬¸½¨¸¸ Ÿ¸½¿ To
©¸¸‰¸¸ œÏ¸›š¸ˆÅ The Branch Manager
____________________________ ©¸¸‰¸¸ Branch
Ÿ¸ÿ, ‚œ¸›¸½ ¹›¸Ÿ›¸ ŠÏ¸−ˆÅ ‚¸ƒÄ”ú ˆ½Å ¹¥¸‡ ‚¸œ¸ˆÅú ƒ¿’£›¸½’ ¸¾¿¹ˆ¿ÅŠ¸ ¬¸½¨¸¸ (¨¸ú-›¸½’ ¸¾¿¹ˆ¿ÅŠ¸) ˆ½Å œÏ¡¸¸½Æ÷¸¸ ˆ½Å ³œ¸ Ÿ¸½¿ ‚œ¸›¸¸ œ¸¿¸úˆ £µ¸ ˆÅ£›¸¸ ¸¸−÷¸¸/¸¸−÷¸ú −»Â.
I wish to register myself as a user of your Internet Banking Service (V-Net Banking) for my following Customer IDs.
›¸¸Ÿ¸ Name

¸›Ÿ¸ ¹÷¸¹˜¸ Date of Birth / /

¹™ D ¹™ D / Ÿ¸¸ M Ÿ¸¸ M / ¨¸ Y ¨¸ Y ¨¸ Y ¨¸ Y

”¸ˆÅ œ¸÷¸¸ Mailing Address

©¸−£ City

jkT; State

jk"Vª Country

¹œ¸›¸ ˆ»Å’ Pin Code

ˆÅ¸¡¸¸Ä¥¸¡¸ œ¸÷¸¸ Office Address

©¸−£ City

jkT; State

jk"Vª Country

¹œ¸›¸ ˆ»Å’ Pin Code

e¨ckbYk la[;k Mobile No

œ¸¾€Æ¬¸ ¬¸¿. Fax No.

ƒÄ-Ÿ¸½¥¸ œ¸÷¸¸ E-Mail Address

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 ŠÏ¸−ˆÅ ‚¸ƒÄ ”ú Customer ID ‰¸¸÷¸¸ ¬¸¿‰¡¸¸ Account Numbers
1.
2.
3.
4.
5.
Ÿ¸ÿ ¹›¸Ÿ›¸ ¬¸½¨¸¸‚¸½¿ ˆ½Å ¹¥¸‡ ‚œ¸›¸¸ œ¸¿¸úˆÅ£µ¸ ˆÅ£›¸¸ ¸¸−÷¸¸/¸¸−÷¸ú −»Â
I wish to register myself for following services
ÇÅŸ¸ ¬¸¿. ¬¸½¨¸¸‡Á¿ ¬¸½¨¸¸‚¸½¿ ˆÅú ‚›¸ºŸ¸¹÷¸ ˆ½Å ¹¥¸‡ ¹¸â ¥¸Š¸¸‡Á¿
Sl No Services Tick the Box to allow the Access
1 ‰¸¸÷¸½ ˆÅú ¬¸»¸›¸¸ Account Information
2* ¹›¸¹š¸ ‚¿÷¸£µ¸ Funds Transfer
3* vcdkjh o lsok ‘kqYd dk bZ&Hkqxrku E-payment of Excise & Service Tax
* As and when made available

Funds Transfer – Beneficiary Registration (fuf/k varj.k fgrkf/kdkfj;ksa dk l`tu)

vuqjks/k gS fd fuEufyf[kr fgrkf/kdkfj;ksa dk l`tu esjs ;wtj vkbZ-Mh esa djsa rkfd eq>s ml [kkrs esa fuf/k varj.k djus esa lqfo/kk gks ldsa
I request you to register the following as the Beneficiaries for my user Id so as to enable me to transfer funds to these accounts.

fgrkf/kdkfj dk uke Beneficiary Name ‰¸¸÷¸¸ ¬¸¿‰¡¸¸ Account Numbers

1.
2.
3.
4.
5.

‹¸¸½«¸µ¸¸ À Ÿ¸ÿ, ¹¨¸¸¡¸¸ ¸ÿˆÅ ׸£¸ https://www.vijayabankonline.net ¨¸/¡¸¸ „›¸ˆ½Å ¹ˆÅ¬¸ú ‚›¡¸ ¨¸½¸¬¸¸ƒ’ œ¸£ „œ¸¥¸š¸ ƒ¿’£›¸½’ ¸ÿ¹ˆ¿ÅŠ¸ ¬¸½¨¸¸‚¸½¿ ˆÅú ©¸÷¸¸½ô ¨¸ ¹›¸¸¿š¸›¸¸½¿ ¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ¨¸ Ÿ¸º¸ œ¸£ ¸¸š¡¸ˆÅ¸£ú −¸½¿Š¸½. Ÿ¸ÿ, ¹¨¸¸¡¸¸ ¸ÿˆÅ
׸£¸ ‚œ¸›¸½ ¹¨¸¨¸½ˆÅ œ¸£ ¬¸Ÿ¸¡¸-¬¸Ÿ¸¡¸ œ¸£ ¹ˆÅ‡ ¸¸›¸½¨¸¸¥¸½ ¹ˆÅ¬¸ú ž¸ú œ¸¹£¨¸÷¸Ä›¸ ˆ½Å ¹¥¸‡ ‚œ¸›¸ú ¹¥¸¹‰¸÷¸ ¬¸−Ÿ¸¹÷¸ œÏˆÅ’ ˆÅ£÷¸¸ −»¿. Ÿ¸ÿ Ÿ¸¸›¸÷¸¸ −»¿ ¹ˆÅ ¸ÿˆÅ ‚œ¸›¸ú œ¸»µ¸Ä ¹¨¸¨¸½ˆÅ œ¸£ ¹¸›¸¸ Ÿ¸º¸½ œ¸»¨¸Ä ¬¸»¸›¸¸ ¹™‡ œ¸»µ¸Ä÷¸À ¡¸¸ ‚¿©¸÷¸À ¡¸½ ¬¸½¨¸¸‡¿
£¸½ˆÅ ¬¸ˆÅ÷¸¸ −¾. ¬¸¸˜¸ −ú Ÿ¸ÿ ¹¨¸¸¡¸¸ ¸ÿˆÅ ˆÅ¸½, ƒ¿’£›¸½’ ¸ÿ¹ˆ¿ÅŠ¸ ¬¸½¨¸¸‡¿ œÏ™¸›¸ ˆÅ£›¸½ ˆ½Å ¹¥¸‡ ÷¸÷¬¸¿¸¿š¸ú ¥¸½›¸™½›¸ ¬¸½ ¸º”õú ˆÅ¸½ƒÄ ž¸ú œÏž¸¸£ ‚œ¸›¸½ ‰¸¸÷¸½ ˆ½Å ›¸¸Ÿ¸½ ”¸¥¸›¸½ ˆÅ¸ œÏ¸¹š¸ˆÅ¸£ ™½÷¸¸ −»¿.
Declaration : I agree and bound by the Terms & Conditions of Internet Banking Services made available by Vijaya Bank at https://www.vijayabankonline.net and/or any other Websites the Bank may
adopt. I also place on record our consent for all the changes that may be made from time to time by the Bank at its sole discretion. I understand that the bank may, at its absolute discretion,
discontinue the service(s) completely or partially without any notice to me. I further authorize Vijaya Bank to debit my Account(s) towards any charges for extending the Internet Banking Services
and/or any other charges connected with Internet Banking transactions.

Ÿ¸ÿ ‹¸¸½¹«¸÷¸ ˆÅ£÷¸¸ −»¿ ¹ˆÅ ƒ¬¸ ‹¸¸½«¸µ¸¸ œ¸°¸ Ÿ¸½¿ ¹™‡ Š¸‡ ¬¸ž¸ú ¡¸¸¾£½ ‚¸¾£ ¬¸»¸›¸¸ (‚¸¾£ ¡¸−¸¿ ¬¸¿™¹ž¸Ä÷¸ ¡¸¸ œÏ¬÷¸º÷¸ ¬¸ž¸ú ™¬÷¸¸¨¸½¸) œ¸»µ¸Ä÷¸À ¬¸÷¡¸, ¬¸−ú, ¬¸¿œ¸»µ¸Ä ‚¸¾£ ‚Ô¸÷¸›¸ −¾ ‚¸¾£ −Ÿ¸›¸½ ¹¨¸¸¡¸¸ ¸ÿˆÅ ¬¸½ ˆÅ¸½ƒÄ ¬¸»¸›¸¸ ›¸−ì Žºœ¸¸¡¸ú −¾. Ÿ¸ÿ
¬¸−Ÿ¸÷¸ −»¿ ¹ˆÅ Ÿ¸½£½ ׸£¸ œÏ¬÷¸º÷¸ ˆÅ¹÷¸œ¸¡¸ ¹¨¸¨¸£µ¸ ¸ÿ¹ˆ¿ÅŠ¸ ˆ¿Åœ¸¹›¸¡¸¸½¿ œ¸£ ¥¸¸Š¸» œ¸¹£¸¸¥¸›¸¸÷Ÿ¸ˆÅ Ÿ¸¸Š¸Ä¹›¸™½Ä©¸¸½¿ ˆ½Å ‚›¸º¬¸¸£ ‚œ¸½¹®¸÷¸ −¾. Ÿ¸ÿ ƒ¬¸¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ‚¸¾£ ¨¸¸›¸ ™½÷¸¸ −»¿ ¹ˆÅ Ÿ¸ÿ ¹¨¸¸¡¸¸ ¸ÿˆÅ ׸£¸ ‚œ¸½¹®¸÷¸ ˆÅ¸½ƒÄ ž¸ú ‚¹÷¸¹£Æ÷¸
¸¸›¸ˆÅ¸£ú œÏ¬÷¸º÷¸ ˆÅ³¿Š¸¸.
I declare that all the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and we have
not withheld any information from Vijaya Bank. I understand that certain particulars given by me are required by the operational guidelines governing banking companies. I agree and undertake to
provide any further information that Vijaya Bank may require.

Ÿ¸ÿ ƒ¬¸¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ‡¨¸¿ Ÿ¸¸›¸÷¸¸ −»¿ ¹ˆÅ ¹¨¸¸¡¸¸ ¸ÿˆÅ Ÿ¸º¸½ ¹¸›¸¸ ˆÅ¸½ƒÄ ˆÅ¸£µ¸ ¸÷¸¸‡ Ÿ¸½£½ ‚¸¨¸½™›¸ œ¸°¸ ˆÅ¸½ ›¸¸Ÿ¸¿¸»£ ¡¸¸ ¹ˆÅ¬¸ú ž¸ú ‰¸¸÷¸½ Ÿ¸½¿ ƒ¿’£›¸½’ ¸ÿ¹ˆ¿ÅŠ¸ ¬¸º¹¨¸š¸¸ ˆÅ¸½ £¸½ˆÅ ¡¸¸ ¸¿™ ˆÅ£ ¬¸ˆÅ÷¸¸ −¾. Ÿ¸ÿ ƒ¬¸¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ¹ˆÅ ¹¨¸¸¡¸¸ ¸ÿˆÅ
‚¸¨¸½™›¸ œ¸°¸¸½¿ ÷¸˜¸¸ „›¸ˆ½Å ¬¸¸˜¸ œÏ¬÷¸º÷¸ œ¸€¸½’¸½ ¨¸ ™¬÷¸¸¨¸½¸¸½¿ ˆÅ¸½ ‚œ¸›¸½ œ¸¸¬¸ £‰¸›¸½ ˆÅ¸ ‚¹š¸ˆÅ¸£ £‰¸÷¸¸ −¾ ‚¸¾£ ƒ›−½¿ Ÿ¸º¸½ ¨¸¸œ¸¬¸ ›¸−ì ˆÅ£½Š¸¸.
I agree and understand that Vijaya Bank reserve the right to reject any application or block the Internet Banking facility to any account or withdraw the Internet Banking service without assigning any
reason. I agree and understand that Vijaya Bank reserves the right to retain the application forms, and the documents provided therewith, including photographs, and will not return the same to me.

Ÿ¸ÿ ƒ¬¸¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ‡¨¸¿ Ÿ¸¸›¸÷¸¸ −»¿ ¹ˆÅ ¹¨¸¸¡¸¸ ¸ÿˆÅ ¬¸½ ¹¨¸¹©¸«’ ™½¡¸÷¸¸ „÷œ¸¸™/¬¸½¨¸¸‚¸½¿ ˆ½Å ¹¥¸‡ Ÿ¸º¸½ ‚›¡¸ ‚¸¨¸½™›¸ ¬¸¿¸¿š¸ú ‚¸¾œ¸¸¸¹£ˆÅ÷¸¸ œ¸»£ú ˆÅ£›¸ú −¸½Š¸ú ÷¸˜¸¸ ¨¸½ ‚¸¨¸½™›¸ ƒ¬¸ ‚¸¨¸½™›¸ œ¸°¸ ˆ½Å ‚¹ž¸››¸ ‚¿Š¸ ˆ½Å ³œ¸ Ÿ¸½¿ (‚¸¾£
¹¨¸œ¸£ú÷¸ ÇÅŸ¸ ¬¸½), Ÿ¸¸›¸½ ¸¸‡¿Š¸½ ÷¸˜¸¸ ¸¸ ÷¸ˆÅ ¹ˆÅ ‡½¬¸½ ‚¹÷¸¹£Æ÷¸ œ¸€¸Ÿ¸¸½ô Ÿ¸½¿ ¹›¸š¸¸Ä¹£÷¸¸›¸º¬¸¸£ ‚›¡¸˜¸¸ œÏˆÅ’ ›¸ ¹ˆÅ¡¸¸ Š¸¡¸¸ −¸½, „¬¸Ÿ¸½¿ œÏ¬÷¸º÷¸ ¡¸¸¾£½ ‚¸¾£ ¬¸»¸›¸¸ ÷¸˜¸¸ ¬¸¿™¹ž¸Ä÷¸ ¡¸¸ œÏ¬÷¸º÷¸ ™¬÷¸¸¨¸½¸ −£ œÏˆÅ¸£ ¬¸½ ¬¸÷¡¸, ¬¸¿œ¸»µ¸Ä ‚¸¾£
‚Ô¸÷¸›¸ −¸½¿Š¸½. Ÿ¸ÿ ƒ¬¸¬¸½ ¬¸−Ÿ¸÷¸ −»¿ ‡¨¸¿ Ÿ¸¸›¸÷¸¸ −»¿ ¹ˆÅ ‡½¬¸½ ‚¹÷¸¹£Æ÷¸ ‚¸¨¸½™›¸ œ¸£ ‚¸¨¸½™›¸ œ¸°¸ ¬¸¿‰¡¸¸, ‚¸¾£/¡¸¸ ‡½¬¸½ ¡¸¸¾£½ ©¸¸¹Ÿ¸¥¸ ˆÅ£›¸½ −¸½¿Š¸½ ¸¾¬¸¸ ¹ˆÅ ¹¨¸¸¡¸¸ ¸ÿˆÅ ”½’¸ œÏ¸¿š¸›¸ ˆ½Å ¹¥¸‡ ¬¸Ÿ¸¡¸-¬¸Ÿ¸¡¸ œ¸£ ¹›¸š¸¸Ä¹£÷¸ ˆÅ£½¿.
I agree and understand that I have to complete further applications for specific liability products/services from Vijaya Bank, as prescribed from time to time, and that such further applications shall be
regarded as an integral part of this application (and vice versa), and that unless otherwise disclosed in such further forms as prescribed, the particulars and information set forth herein as well as the
documents referred or provided herewith are true, complete and up-to-date in all respects. I agree and understand that such further applications will require incorporation of the application form
number, and/or such details as Vijaya Bank may prescribe, to facilitate data management.

---------------------------------------------------
ŠÏ¸−ˆÅ ˆ½Å −¬÷¸¸®¸£ SIGNATURE OF CUSTOMER
Page 2 of 3
©¸¸‰¸¸ ˆ½Å œÏ¡¸¸½Š¸ ˆ½Å ¹¥¸‡ FOR BRANCH USE
(¡¸¹™ ŠÏ¸−ˆÅ ˆ½Å œ¸¸¬¸ „›¸ˆ½Å ‰¸¸÷¸¸½¿ ˆ½Å ¹¥¸‡ ‚¥¸Š¸-‚¥¸Š¸ ŠÏ¸−ˆÅ ‚¸ƒÄ”ú −¸½ ÷¸¸½, ‚¸¨¸½™›¸ œ¸°¸ ˆÅ¸½ ¬¸¿¬¸¸¹š¸÷¸ ˆÅ£›¸½ ˆ½Å ¹¥¸‡ ”¸’¸ ˆ¿½ÅÍ Ÿ¸½¿ ‚ŠÏ½¹«¸÷¸ ˆÅ£›¸½ ¬¸½ œ¸−¥¸½ ƒ›¸ ¬¸¸ ŠÏ¸−ˆÅ ‚¸ƒÄ”ú ˆÅ¸½ ‡ˆÅ −ú ŠÏ¸−ˆÅ ‚¸ƒÄ”ú ˆ½Å ‚¿÷¸Š¸Ä÷¸
¥¸¸›¸¸ −¸½Š¸¸. ©¸¸‰¸¸ ˆÅ¸½ ¬¸÷¡¸¸¹œ¸÷¸ ˆÅ£›¸¸ −¸½Š¸¸ ¹ˆÅ ¬¸ž¸ú ‰¸¸÷¸½ ¨¸ ŠÏ¸−ˆÅ ‚¸ƒÄ”ú „¬¸ú ŠÏ¸−ˆÅ ˆ½Å −ÿ)
(If Customer has different Cust Ids for his accounts then all these Cust Ids has to be merged to one Cust Id, before forwarding the application to Data Center for processing. Branch has to verify that
all accounts & Cust Ids belongs to that customer only)

‚¸¨¸½™ˆÅ ˆÅ¸ ›¸¸Ÿ¸ Applicant's name

ŠÏ¸−ˆÅ ‚¸ƒÄ”ú Customer ID

©¸¸‰¸¸ ˆ»Å’ Branch Code ©¸¸‰¸¸ ˆÅ¸ ›¸¸Ÿ¸ Branch Name

©¸¸‰¸¸ ¬¸¿™ž¸Ä ¬¸¿.

Branch Reference No.
ŠÏ¸−ˆÅ ‚¸ƒÄ”ú, œ¸÷¸¸ ¨¸ −¬÷¸¸®¸£ ¬¸÷¡¸¸œ¸›¸ˆÅ÷¸¸Ä
Customer ID, Address & Signature Verified
by
−¬÷¸¸®¸£ ¨¸ ›¸Ÿ¸»›¸¸ −¬÷¸¸®¸£ ¬¸¿.
Signature & SS No.
¹™›¸¸¿ˆÅ Date / /
©¸¸‰¸¸ ˆÅú ¹¬¸œ¸ö€¸¹£©¸ ƒ¿’£›¸½’ ¸¾¿¹ˆ¿ÅŠ¸ ¬¸º¹¨¸š¸¸ ‚›¸ºŸ¸÷¸ ƒ¿’£›¸½’ ¸ÿ¹ˆ¿ÅŠ¸ ¬¸º¹¨¸š¸¸ ›¸¸Ÿ¸¿¸»£
Branch Recommendation Internet Banking Facility Permitted Internet Banking Facility Not Permitted
‚ž¡¸º¹Æ÷¸¡¸¸Á Remarks

©¸¸‰¸¸ œÏ¸¿š¸ˆÅ (›¸¸Ÿ¸ ¨¸ −¬÷¸¸®¸£)

Branch Manager (Name & Signature)
¹™›¸¸¿ˆÅ Date / /
”¸’¸ ˆ½¿ÅÍ ˆ½Å œÏ¡¸¸½Š¸ ˆ½Å ¹¥¸‡ FOR DATA CENTER USE
‚¸¸¿¹’÷¸ œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú ALLOTTED USER ID

¹™›¸¸¿ˆÅ Date ›¸Ÿ¸»›¸¸

¬¸¿™ž¸Ä −¬÷¸¸®¸£
(¹™¹™/Ÿ¸¸Ÿ¸¸/¨¸¨¸¨¸¨¸) −¬÷¸¸®¸£ ¬¸¿.
Events Signature
(DD/MM/YYYY) SS No.
¬¸ú‚¸£‡Ÿ¸ ”¸’¸ ¬¸÷¡¸¸¹œ¸÷¸
CRM Data Verified / /
œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú ¹›¸¹Ÿ¸Ä÷¸
User ID Created / /
œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú œÏ¸¹š¸ˆ¼Å÷¸
User ID Authorised / /
œ¸¸¬¸¨¸”Ä ¸¹›¸÷¸
Password Generated / /
œ¸¸¬¸¨¸”Ä Ÿ¸º¹Í÷¸
Password Printed / /
œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú œÏ½¹«¸÷¸
User Id Dispatched / /
¹œ¸›¸ Ÿ¸½ƒ¥¸£ œÏ½¹«¸÷¸
PIN Mailer Dispatched / /
œ¸¸¨¸÷¸ú œÏ¸œ÷¸
Acknowledgement Received / /
œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú ¬¸®¸Ÿ¸
User ID Enabled / /
ˆºÅ¹£¡¸£ ¹¨¸¨¸£µ¸ Courier Details
œÏ¡¸¸½Æ÷¸¸ ‚¸ƒÄ”ú Ÿ¸½ƒ¥¸£ USER ID MAILER
Ÿ¸½ƒ¥¸£ ¬¸¿™ž¸Ä ¬¸¿. Mailer Reference No
ˆºÅ¹£¡¸£ ˆÅ¸ ›¸¸Ÿ¸ Courier Name
£¬¸ú™ ¬¸¿. Receipt No.
¹œ¸›¸ Ÿ¸½ƒ¥¸£ PIN MAILER
Ÿ¸½ƒ¥¸£ ¬¸¿™ž¸Ä ¬¸¿. Mailer Reference No
ˆºÅ¹£¡¸£ ˆÅ¸ ›¸¸Ÿ¸ Courier Name
£¬¸ú™ ¬¸¿. Receipt No.

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