Service Request Form

To From
Head of ADC Name : ___________________________
Exim Bank Limited Designation :___________________________
Head Office Address :___________________________
"SYMPHONY" ___________________________
Plot # SE (F): 9, Road # 142 ___________________________
Gulshan Avenue, Tel ____________________________
Dhaka- 1212

Dear Sir,

Ref: Card No. - - - Expiry :__/__/__

I would like to request for the following:

1. Card bill Statement From……………………………..to………..………..………………….……

2. Replacement of Card………………………………………………………………………….……

3. Replacement of PIN…………………………………………………………….……………….…

4. Activation/Reactivation of Cards……………………………………………….…………….……

5. E-Commerce: Number of transaction .…………………………… Amount …………..…………

web address ……………………………….……………………….………………………………

6. Waiver of Annual Fees (Reason):………………………………………………………….………

7. Present Mailing Address as:……………………………………………………...……….………..

8. Refund: Amount: USD…………………..…TT Clean rate: …….….…BDT: ……….………..…

Refund to Account No. …………….………….……………….……… P.O By Card

9. Others (Please Specify):………………………………………………………...………….………

I have authorized above instruction.

Thanking you,
Sincerely

_________________ ___________________________________
Cardholder Signature Authorised Signature with PA number & Seal
Date: (Branch/Others)

For ADC use only

Signature Verified By:…………………………………………Date:……………………………….

File No………………………………
Action taken By………………………………………………..On………………………………….