,dy O;fDr ds fy, izhisM ih,uch

lqfo/k dkMZ gsrq vkosnu QkeZ Øsrk dk QksVksxzkQ

'kk0dk0____________________________ fof'k"V la0 _________________________

1. Øsrk dk uke Jh@lqJh

2. ih,uch xzkgdksa ds fy, % [kkrk la0

3. xSj ih,uch Øsrk ds ekeys esa %
d- cSad [kkrk cSad __________________'kk[kk_______________vkbZ,Q,llh dksM____________________
[k- [kkrk la0

x- tUe frfFk fn fn e e o o o o
?k- eksckbZy ua0 (vfuok;Z)
M- bZ&esy vkbZMh % _______________________________________

p- i=kkpkj gsrq irk %

N- dsokbZlh gsrq tek nLrkost 1. ___________________________ 2. ___________________________

3. ___________________________ 4. ___________________________
4. dkMZ esa Mky tkus okyh jkf'k #0 __________________(jkf'k 'kCnksa esa__________________________________________)
5. ?kks"k.kk % eSa ?kks"k.kk djrk@djrh gwa fd vkosnu i=k esa nh xbZ lwpuk esjh tkudkjh ds vuqlkj lR; vkSj lgh gSA
6. Lohd`fr dh 'krs± ,ao fuca/u % eSa Lohdkj djrk gw¡@djrh gw¡ fd ih,uch ds ikl dksbZ dkj.k crk;s fcuk bl vkosnu i=k dks Lohdkj vFkok vLohdkj
djus dk iw.kZ foosdkf/dkj gSA ;g esjh ftEesnkjh gS fd cSad dh osclkbV ij ;Fkkiznf'kZr ih,uch lqfo/k dkMZ ij ykxw 'krs± ,ao fuca/uksa dk ikyu d:a
vkSj mls le>waA ;fn ;g vkosnu i=k Lohdkj fd;k tkrk gS rks ih,uch lqfo/k dkMZ ls lacaf/r 'krks± o fuca/uksa dk] tks le;≤ ij ykxw gks ldrs
gSa] dk ikyu d:axk@d:axh vkSj dkMZ ds esjs }kjk iz;ksx fd;s tkus dks bu 'krks± ,ao fuca/uksa dks Lohdkjuk le>k tk;sxkA eSa tkurk gwa@tkurh gwa fd
blls lger gksus ds ckn eSa ;g nyhy ugha ns ldrk@ldrh fd eq>s 'krs± ,ao fuca/uksa dh tkudkjh ugha gSA eSa esjs dk;kZy;@vkokl ij vFkok eq>ls@esjs
fu;ksDrk@cSadj ls fdlh izdkj dh lwpuk vFkok vU;Fkk dk lR;kiu djus vFkok fdlh vU; lzksr ls dksbZ tkudkjh izkIr djus vFkok nsus ds fy,]
tks lnL;rk dh vko'kdrkvksa dh iqf"V djus vFkok esjk [kkrk vPNh fLFkfr esa j[kus ds fy, visf{kr gks] ds fy, ih,uch dks izkf/d`r djrk gwa@djrh
gwaA esjh vksj ls 'krks± ,ao fuca/uksa dh vuqikyuk u gksus dh fLFkfr esa vFkok esjs }kjk nh xbZ fdlh lwpuk ds xyr vFkok mfpr u gksus dh fLFkfr esa] eSa
lger gwa fd ih,uch lqfo/k dkMZ ds [kjhnus vkSj bLrseky djus ij ykxw] LFkkuh; fof/ vkSj@;k fofu;euksa ds varxZr fdlh@lHkh 'kkfLr;ksa vkSj@;k
dk;Zokgh tks Hkh ykxw gS] ds fy;s vdsys gh ftEesnkj gksÅaxk@gksÅaxhA eSa ;g Hkh le>rk gwa fd lHkh Qhl] C;kt vkSj vU; izHkkjksa ij Hkkjr ljdkj ds
fofu;euksa ds vuq:i fu/kZfjr njksa ij lsok dj ykxw gSa vkSj eSa bUgsa pqdkus ds fy, lger gwaA eSa lger gwa fd dkMZ dh lekfIr ds le;@dkMZ dh lekfIr
frfFk ls 3 ekg ds Hkhrj vnkokd`r@u HkqukbZ xbZ lHkh miyC/ jkf'k;ka cSad esa mifpr gksaxhA

fnukad : Øsrk ds gLrk{kj

dsoy 'kk[kk ds iz;ksx gsrq (dkMZ dk C;kSjk)
6. tkjh ih,uch lqfo/k dkMZ la0
7. izkjfEHkd dkMZ esa Mkyh xbZ jkf'k ___________________(jkf'k 'kCnksa eas ________________________________________________)
bl vkosnu i=k ds lkFk nh x;h oS/ ^igpku i=k* ds lk{; vkSj irs ds lk{;ksa dh izfr;ksa ds ewy nLrkostksa ls fof/or lR;kiu fd;k x;k gSA Øsrk dk
QksVksxzkQ lR;kfir gSA

izkf/d`r gLrk{kjdrkZ izkf/d`r gLrk{kjdrkZ

mi;qZDrkuqlkj izkIr ih,uch lqfo/k dkMZ

Øsrk ds gLrk{kj
 APPLICATION FORM FOR PNB SUVIDHA
PREPAID CARD FOR INDIVIDUALS
Photograph of
B.O. ______________________________ Distinctive No. _________________________ Purchaser

1. Name of purchaser Mr./Ms.

2. For PNB Customers : Account No.

3. In case of Non-PNB Purchaser:

a. Bank Account with Bank ________________Branch ______________IFSC Code______________

b. Account Number

c. Date of Birth d d m m y y y y

d. Mobile No. (Mandatory)

e. Email Id: _______________________________________
f. Address for Communication :

Documents submitted for KYC: 1. ___________________________ 2. ___________________________

3. ___________________________ 4. ___________________________

4. Amount to be loaded on the Card Rs. ____________(Amt in words: Rs___________________________________)

5. Declaration: I declare that the information provided in the application is true and correct to the best of my knowledge.

6. Acceptance of Terms and Conditions : I accept that PNB has absolute discretion to accept or reject this application without
assigning any reason whatsoever. It is my responsibility to adhere to the terms and conditions as applicable to the PNB SUVIDHA Card
as displayed on the Bank’s website and understand the same. If this application is accepted, I shall adhere to the terms and conditions
governing the PNB SUVIDHA Card, as may be in force from time to time and my usage of the card shall be deemed to be acceptance
of those terms and conditions. I am aware that by agreeing to this I am estopped from taking a plea subsequently that am not aware of
the Terms and Conditions. I authorize PNB to verify any information or otherwise at my office/residence or to contact me, my Employer/
Banker or any other source to obtain or provide any information that may be required for confirming membership requirements or
maintaining my account in good standing. In the event of any failure on my part to comply with the rules and regulations or in the event
of any information supplied by me being incorrect or inaccurate, I agree that I will be solely liable for any/ all penalties and/or action under
the local laws and/or regulations as may be in force, governing the purchase and use of the PNB SUVIDHA Card. I also understand that
Service Tax at stipulated rates is applicable on all fees, interest and other charges as the Government of India regulations and agree to
pay the same. I agree that all available amounts at the time of expiry of the Card not claimed/ en-cashed within 3 months from date of
expiry of the Card shall accrue to the Bank.

Date : Signature of Purchaser

FOR BRANCH USE ONLY (CARD DETAILS)

6. ISSUED PNB UPHAAR CARD No. :

7. Amount Loaded on the Card Rs. ______________(Amount in words: Rs. ______________________________)
Copies of the valid ID Proof and Address Proof submitted with this application have been duly verified with the original.
The photograph of the purchaser is verified.

Authorized Signatory Authorized Signatory

Received PNB Suvidha Card As Above

Signature of Purchaser

iauScSa PNB 1178 — 118/14 MPP