National Bank Limited

CARD DIVISION
Customer Requisition Form

Card Number:

Customer’s Name: _______________________________________________________

Date of Birth: □□ □□ □□ Card Type: □ Debit card □ Credit card

Mother’s Name: _____________________ Father’s Name: ____________________

I would like to request for the following:

1. Enhancement of credit limit from………………………….. to …………………
(Please attach latest pay slip and 4 months’ bank statement for salaried persons
and 12 months’ bank statement for business man as applicable)
2. Renewal /Reactivation of card (Please specify the reason of withheld
renewal) …..……………………………………………………………….……...
3. Early Renewal Required (Please Specify reason)…………………………………
4. Replacement of card (Please Specify reason)………………………..……………
5. Reissue the PIN (Please Specify Reason)…………………………………………
6. Cancellation of card (Please Specify reason)……………………………………...
7. Add / cancel on of Auto Debit instruction (Please insert your A/C No.) Account
No……………..……….Branch………..…….…..….…… For: Min /……….…..%
8. Removal of lien A/C (Please insert your lien A/C No.)
Account No……………..………..…. Branch……………….…..…...…..….……
9. Waiver of late payment fee/ debit interest/annual fee (Please Specify
reason) ……………………………………………….……………………………
10. Conversion of Card (Present Status………………………….…….……………...
Converted Status………………………………..………………..……………….)
11. CIB Clearance from Bangladesh Bank……………………………………………..
12. Others……………………………………………………………………………….
Commitment (if any): ……………………………………………………………………….
……………………………………………………………………………………….………
Thanking you.

Cardholder signature
Address: ________________________________________________ Date: ___________
Contact No.__________________
________________________________________________________________
*Relevant bank charges are applicable. 24 hour service desk:
Securites Details check (Bank Use only): Tel:+88-2-9650825-32,Ext.151-160
□Date of birth □Contact no Mobile: 01711287222, 01713048666
□Mother’s Maiden Name Fax: 88-2-9650820
□Supplementary Card Name (If Any) Email:nblccd@bol-online.com
□Other:

Checked By Authorised By
Date: Date: