CORPORATE

Branch In-charge Date:

………………………………Branch Internet Banking Application
BASIC Bank Limited
Applicant’s Request Type (Please give tick where applicable)

New Account A/C Delete Reset Password Modify (Specify)…………………………………

CIF No. :

Account No. (Deposit) :

Account Title

Telephone No.*

Mobile No.

E-mail Address

Mailing Address*

I/We hereby declare that the above information are true and correct and that I/we have read and signed the General
Instructions attached with this application and shall abide by the Terms & Conditions for using Internet Banking
Services of the Bank as stipulated in the Internet Banking Portal (ib.basicbanklimited.com) of the Bank.

I/We further mention that Mr./Mrs.……………………………………………………………………………………………………., CIF

No…….………………………………and Designation …………………………………………….is authorized to operate Internet Banking
account.

Name Signature
1st signatory

2nd signatory

3rd signatory

Branch Use Only

Information & Signature verified by: Recommended by:

(Authorized signature & Seal) (Branch In charge/Operation Manager)

Card Division Use Only

IB Application Received Date: Authorized Signature

New User Request creation Date: Authorized Signature

Security Envelope Received date: Authorized Signature

Security Envelope dispatch date Authorized Signature