fot;k cSad VIJAYA BANK

foHkkx % lwpuk o izks|ksfxdh

Dept : Information Technology

iz/kku dk;kZy; Head Office,

41/2, egkRek xka/kh jksM MG Road,
csaxywj BANGALORE - 560 001

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V-NET BANKING APPLICATION FORM
( For Individuals)

Date

To

The Branch Manager

____________________________ Branch
, (- ) / .
I wish to register myself as a user of your Internet Banking Service (V-Net Banking) for my following Customer IDs.
Name
Date of Birth
D

/
/

/
/

yx

iq#"k

Gender

Male

h
Female

Mailing Address

- City
jkT; State
jk"V Country

Pin Code

Office Address

- City
jkT;

State

jk"V Country

Pin Code

eckbYk la[;k Mobile No

. Fax No.
- E-Mail Address

Page 1 of 3

 Customer ID

Account Numbers

1.
2.
3.
4.
5.
/
I wish to register myself for following services
.
Sl No
1

Services

Tick the Box to allow the Access

Account Information

2*

Funds Transfer

3*

vcdkjh o lsok kqYd dk bZ&Hkqxrku E-payment of Excise & Service Tax

* As and when made available

Funds Transfer Beneficiary Registration

(fuf/k varj.k fgrkf/kdkfj;ksa dk l`tu)

vuqjks/k gS fd fuEufyf[kr fgrkf/kdkfj;ksa dk l`tu esjs ;wtj vkbZ-Mh esa djsa rkfd eq>s ml [kkrs esa fuf/k varj.k djus esa lqfo/kk gks ldsa
I request you to register the following as the Beneficiaries for my user Id so as to enable me to transfer funds to these accounts.

fgrkf/kdkfj dk uke Beneficiary Name

Account Numbers

1.
2.
3.
4.
5.
, https://www.vijayabankonline.in / . ,
- .
. , .
Declaration : I agree and bound by the Terms & Conditions of Internet Banking Services made available by Vijaya Bank at https://www.vijayabankonline.in and/or any other Websites the
Bank may adopt. I also place on record our consent for all the changes that may be made from time to time by the Bank at its sole discretion. I understand that the bank may, at its absolute
discretion, discontinue the service(s) completely or partially without any notice to me. I further authorize Vijaya Bank to debit my Account(s) towards any charges for extending the Internet Banking
Services and/or any other charges connected with Internet Banking transactions.
( ) , , .
.
.
I declare that all the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and we have
not withheld any information from Vijaya Bank. I understand that certain particulars given by me are required by the operational guidelines governing banking companies. I agree and undertake to
provide any further information that Vijaya Bank may require.
.
.
I agree and understand that Vijaya Bank reserve the right to reject any application or block the Internet Banking facility to any account or withdraw the Internet Banking service without assigning any
reason. I agree and understand that Vijaya Bank reserves the right to retain the application forms, and the documents provided therewith, including photographs, and will not return the same to me.
/ (
), , ,
. , / - .
I agree and understand that I have to complete further applications for specific liability products/services from Vijaya Bank, as prescribed from time to time, and that such further applications shall be
regarded as an integral part of this application (and vice versa), and that unless otherwise disclosed in such further forms as prescribed, the particulars and information set forth herein as well as the
documents referred or provided herewith are true, complete and up-to-date in all respects. I agree and understand that such further applications will require incorporation of the application form
number, and/or such details as Vijaya Bank may prescribe, to facilitate data management .

-------------------------------------------------- SIGNATURE OF CUSTOMER

Page 2 of 3

 FOR BRANCH USE

( - ,
. )
(If Customer has different Cust Ids for his accounts then all these Cust Ids has to be merged to one Cust Id, before forwarding the application to Data Center for processing. Branch has to verify that
all accounts & Cust Ids belongs to that customer only)
Applicant's name
Customer ID
Branch Code

Branch Name

.
Branch Reference No.
,
Customer ID, Address & Signature Verified
by
- .
Signature & SS No.

Branch Recommendation
Remarks

Date

Internet Banking Facility Permitted

Internet Banking Facility Not Permitted

( )
Branch Manager (Name & Signature)

Date

FOR DATA CENTER USE

ALLOTTED USER ID
Date
(//)
(DD/MM/YYYY)

Events

CRM Data Verified

User ID Created

User ID Authorised

Password Generated

Password Printed

User Id Dispatched

PIN Mailer Dispatched

Acknowledgement Received

User ID Enabled

/
/
/
/
/
/
/
/
/

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Signature

- .
SS No.

/
/
/
/
/
/
/
/
/

Courier Details
USER ID MAILER
. Mailer Reference No
Courier Name
. Receipt No.
PIN MAILER
. Mailer Reference No
Courier Name
. Receipt No.

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