Date:

To
The Head of Card Department
Social Islami Bank Ltd
15Dilkusha C/A(5th Floor)
Head Office, Dhaka
Subject:Customer Request Form
Dear Sir
I………………………………………………………undersigned have been enjoying a facility of Credit
Card………………………………………………………… I would like to change following information.
Residence Address (Present):
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Telephone: …………………………….. Mobile: ………………………………..
Company Address (present):
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Telephone: …………………………….. Mobile: ………………………………..
E-mail Address: …………………………………………………..

Mailing Address: Residence Address (Present)  Company Address (present)

Mobile Number (If Changed): ……………………………………
E-mail Address: …………………………………………………….
 AutoDebit Instruction- Account no: Amount: MinimumFull
 Increase of Credit Limit up to Tk. ………………..and/or. ……………….USD………….
(I have enclosed the latest income documents/promotion letter as applicable)
Replace/Reissue the card /PIN with reason:
Waiver of late payment charge/excess over limit charge: TK. ……….and/or USD. ……..
Cancellation of Credit Card with reason:
Temporary stop of BASIC/Supplementary with reason:
Credit Card/Debit Card Activation
Limit Conversion BDT to USD & USD to BDT:
Cancelled safe guard premium

Others:
Signature Change
Existing Signature New Signature

Your kind cooperationis needed to change the above address/phone no

Thank you
Sincerely yours

……………………….