Annexure - 2

Application No.
ASSAM GRAMIN VIKASH BANK
(A joint undertaking of Govt. of India, Govt. of Assam & United Bank of India)
Head Office: G S Road, Bhangagarh, Guwahati –781005(Assam)
Website : agvbank.co.in Paste here recent
passport size
photograph of the
APPLICATION FORM FOR ATM CARDS
applicant
(Please read Important Instructions given overleaf before filling up the application)

Dear Sir,
Being desirous of availing the facility of using ATM cum RUPAY Debit Card, I/we furnish the information below :

Please tick (√)the appropriate option :

New Renewal Replacement

Name of
Applicant

Name to be printed on (Max. 25 Letters including spaces)

card

Nationality Gender Male Female

Date of birth DD / MM / YYYY PAN Number AADHAAR No.

Change of Address :
Please update the contact information (Correspondence/Permanent) in your records. I/We am/are enclosing proof my/our new address. My/our current address is:
Address for correspondence :

House No. /Flat No. Ward name/ number Name of the Street/Road

Land mark * Village/ locality * District *

City/ Town * Pin Code * Post Office State *

Mobile No. Landline No. Email Id

9 1

Permanent Address : If same as correspondence Address , please tick (√) here

House No. /Flat No. Ward name/ number Name of the Street/Road

Land mark * Village/ locality * District *

City/ Town * Pin Code * Post Office State *

Mobile No. Landline No. Email Id

9 1

My designated account/s on which I require ATM services :

Primary Account details [Please tick (√) the appropriate option] Savings Current Overdraft KCC

Account Number Customer ID

(CD A/c card will be issued to proprietor only)

Declaration:
I / We hereby declare to abide bythe rules terms & conditions as applicable to Assam Gramin Vikash Bank Rupay Debit Card holder. I/ We will follow the stipulated
guidelines for usage of Assam Gramin Vikash Bank Debit Card and comply with the existing as also the modifications, if any made by the Bank from the time to time without
reference to me / us. I/We also acknowledge that bank may debit applicable charges with regards to my card and I will abide by the same.

Applicant's signature Other

(In case of joint account
account holder/s
holders signatureholders shall
all account
put their signatures)

Date DD / MM / YYYY Date DD / MM / YYYY

Place Place
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Acknowledgement
Received application no…………….. for ATM card from…………………………………… on ……/…../………..

Authorised official’s Signature

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Important Instructions:
◊ Please fill the entire form in CAPITAL LETTERS only
◊ Leave one box space between each word.
◊ Do not write outside the provided boxes
◊ Complete all sections.
◊ Sign the Declaration.
◊ If joint A/C please fill another application form.
◊ Add on card will be issued to accounts with either or survivor / anyone or survivor clause only.
◊ Applicable annual service charges will be levied on ATM cards.
For office use

New Renewal Replacement Date DD / MM / YYYY

Card issuing branch code: Branch name :

Customer/ Link branch code: Branch name :

Mode of operation : Single E or S Anyone or S

In case of replacement/renewal of ATM cards :

Old ATM card No. :
New ATM card No. :

Details of accounts , branch name , branch code , customer ID , Signature & mode of operation of accounts verified and charges levied (wherever applicable)
and authorised to issue card.

Reason _____________________________________________________________________________________________(in case declined to issue card)

Name of verifying authority :

Signature of of verifying authority :

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For Pre-Activated cards

Card Number Date DD / MM / YYYY

Issued by Verified by
Name Name

Signature Signature

"Received the AGVB RUPAY Debit Card welcome kit, in sealed and good condition"

Applicant's signature Other account holder/s signature

(In case of joint account holders all account holders shall put their
signatures)

Date DD / MM / YYYY Date DD / MM / YYYY

Place Place
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Dear customer, thank you for applying for AGVB ATM card.
Do not respond to any call/email/SMS asking for your personal information regarding account number/card number/PINs etc.
For any information / inquiry, please contact your home branch or call us at 99571 83639 / mail us to agvbatm@agvb.co.in or debitcardcare@agvb.co.in