A-A Bhaban (2nd floor)

Card Division 23 Motijheel C/A, Dhaka-1000

Tel: 880 2 9512035
Call Center: 16253, +8809612316253
card@pubalibankbd.com

CARD CUSTOMER SERVICE FORM / KvW© Kv÷gvi mvwf©m dig

Card No.
KvW© bs    
Cardholder’s Name ________________________________________________________________________________________________________________________________
KvW© †nvìv‡ii bvg
Card Type
 Debit Card / ‡WweU KvW©  Credit Card / ‡µwWU KvW©
Kv‡W©i aib
Please update the personal details of my above mentioned Card/ Dc‡i D‡jø¨wLZ Avgvi Kv÷gvi KvW© Gi Avc‡WU Kivi Rb¨ Aby‡iva Kiv n‡jv:
 Name
bvg 
 Date of Birth Photo ID ( NID/Passport)
Rb¥ ZvwiL  d‡Uv AvBwW (GbAvBwW/cvm‡cvU©) 

 Father’s / Mother’s/ Spouse’s Name ____________________________________________________________________________________________________________________

evev/gv/¯^vgx/¯¿x bvg
 New Address _____________________________________________________________________________________________________________________________________
bZzb wVKvbv
 New Mobile/Tel ___________________________________________________ Previous Mobile/Tel ___________________________________________________
bZzb ‡gvevBj/ †Uwj‡dvb cyivZb ‡gvevBj/ †Uwj‡dvb
 New/Updated Email Address _________________________________________________________________________________________________________________________
bZzb/ Avc‡WU B‡gBj
 Any other modification _______________________________________________________________________________________________________________________________
Ab¨vb¨ cwieZ©b
I would like to request for the following
Avwg wb‡¤œv³ wel‡qi Rb¨ Aby‡iva Rvbvw”Q
 Please activate my ecommerce transactions  Local/¯’vbxq  International/AvšÍR©vwZK
AbyMÖn c~e©K Avgvi B-Kgvm© †jb‡`b Pvjy Kiæb
 Please Activate/Pvjy  Deactivate/eÜ Temporary Deactivate/mvgwqK eÜ my card
AbyMÖn c~e©K Avgvi KvW© Pvjy/eÜ/mvgwqK eÜ Kiyb
 Please Activate Deactivate my card for international transactions
AbyMÖn c~e©K Avgvi Kv‡W© AvšÍ©RvwZK †jb‡`b Pvjy/eÜ Kiyb
 Lien A/C change : A/C no
wj‡qb GKvD›U cwieZ©b: GKvD›U bv¤^vi
   Lien amount (as per sanction letter) _________________________
wj‡q‡bi cwigvY (†jv‡bi Aby‡gv`b cÎ Abyhvqx)
 ATM  POS  Transactions Limit Enhancement : Expected Limit ________________________________________ Nos. of transactions _______________________________
__
GwUGg wcIGm †jb‡`‡bi wjwgU ewa©ZKib: cÖ‡qvRbxq wjwgU cÖ‡qvRbxq ‡jb‡`b msL¨v
 Please replace my new account : Present A/C ____________________________________________ Previous A/C __________________________________________
AbyMÖn c~e©K Avgvi bZzb GKvD›U cwieZ©b Kiæb: eZ©gvb GKvD›U Av‡Mi GKvD›U
 Please replace my Card for the following reason / wb‡¤œv³ Kvi‡Y AbyMÖn K‡i Avgvi KvW© cwieZ©b Kiyb:
 Card Broken / Damaged  Card Lost / Stolen  Wrong Photo /Name  Any Other Reason _______
_____________________
KvW© fv½v / bó nIqv KvW© nviv‡bv / Pzwi nIqv fzj Qwe /bvg Ab¨ †Kvb KviY
 Please replace my pin / AbyMÖn K‡i Avgvi wcb cwieZ©b Kiæb:
 PIN Forgotten / wcb fz‡j hvIqv  Any Other Reason / Ab¨ †Kvb KviY __________________________________________________________________________________

 Standing Instruction Setup / ÷¨vwÛs Bb÷ªvKkb †mUAvc  Minimum Amount Due (5%) / b~¨bZg e‡Kqv  Full Outstanding / cy‡iv e‡Kqv ___________________________ %
 Please debit my A/C no. ___________________________________________________ for Credit Card payment through standing Instruction.
AbyMÖn K‡i Avgvi GKvD›U bs ‡WweU K‡i ÷¨vwÛs Bb÷ªvKk‡bi gva¨‡g †µwWU Kv‡W©i e‡Kqv / wej cwi‡kva Kiyb
By signing, I agree to the relevant terms & conditions of the item mentioned above /Avwg wb¤œ-¯^v¶wiZ Dc‡iv³ welq mswkøó kZ©vejx‡Z mg¥Z

Thanking You / ab¨ev`v‡šÍ

_____________________________________ _________________________________
Signature of Cardholder / KvW© †nvìv‡ii ¯^v¶i Date / ZvwiL  Branch Seal & Sign / kvLv mxj I ¯^v¶i

For Bank Use Only / e¨vs‡Ki e¨venv‡ii Rb¨ cÖ‡hvR¨

Instruction Processed by / whwb wb‡`©kbvejx cÖ‡mm Ki‡jb __________________________________________ Sign & Date / ¯^v¶i I ZvwiL _____________________________

Instruction Checked by / whwb wb‡`©kbvejx ‡PK Ki‡jb __________________________________________ Sign & Date / ¯^v¶i I ZvwiL _____________________________