| VIJAYA BANK |
Head
Office
Credit Card Division
41/2, M G Road
Bangalore – 560 001
Phone No : 091-80-5584066 (20
lines)
Telex : 0845 8842 (VBHO IN)
Fax :
091-80-5582915 |
| APPLICATION FOR Vijaya Classic
Visa/Mastercard |
| * Please
complete the application in full using BLOCK
LETTERS |
|
|
| Personal
Details |
| (Please
leave blank space between each name) |
| |
| First Name |
Middle Name |
Surname | |
| Name in full
|
|
| Father's/Husband's Name |
|
| Name to appear in Credit Card |
| |
|
|
|
|
| Date of
Birth |
|
| Sex |
|
| Marital
Status |
|
| Do you own
|
|
| |
Registration No : _____________________ Driving
License No : ___________________ |
| Eductional
Qualification |
________________________________________________________________________ |
| Residence |
|
|
Own |
|
Rented
( Monthly Rent Rs _____________ )
| |
| No of
Dependants |
________________________________________________________________________ |
| Income
Tax/PAN No |
________________________________________________________________________ |
| Are you a
NRI |
|
| Passport
No |
____________________________________________(Copy
to be enclosed) | |
| | | |
| |
| Employment
Details |
| Service |
Salaried |
Self Employed |
Firm/Business/Others |
Employed with
:
____________________ |
|
|
|
| Proprietor |
|
Line of
Business :
___________________
| |
Designation :
____________________ |
|
|
|
| Partner |
|
Annual
Income Rs.
___________________
| |
Length of
Service :
____________________ |
|
|
| |
| |
Annual Income
Rs.
____________________ |
Other Income
Rs.
____________________ |
Total Income Rs.
____________________
| |
|
|
|
|
| Details of
Credit Card issued earlier by Vijaya Bank |
|
Yes |
|
No |
Particulars | |
| Details of
Credit Card issued earlier by Vijaya Bank |
Designation
:
_____________________ |
Branch/Office
:
| |
| |
| Financials
Details |
| ASSETS |
LIABILITIES |
| 1.
Description & Addressof the immovable
properties |
PresentMarket
Value |
Annual Income
From Immovable properties |
Details of business liability |
Amount |
| |
|
|
|
|
| 2. Details of
movable properties including deposits, shares,
debentures etc. |
PresentMarket
Value |
Annual
IncomeFrom Immovable properties |
Details of
business liability |
Amount |
| |
|
|
|
| | | |
| |
| References |
| References
(Other than relatives) |
Address |
Occupation |
Telephone
Nos |
| 1. |
|
|
|
| 2. |
|
|
| |
| |
| Enclosed
|
|
|
Salary
Certificate |
|
|
Proof of Business income |
|
|
Proof of other income |
|
|
Proof of property |
|
|
IT/WT
Order | | |
| |
| Banking Details (SB/CA/OD/CC/NRE) |
| Name of the
branch VIJAYA BANK |
|
A/c No
|
|
| Other Bank
Name & Address |
|
A/c No
|
|
| Other Bank
Name & Address |
|
A/c No
|
| |
| |
| Add-On Card Details |
| Would
you like to have a Add-on Card |
|
Yes |
|
No |
| |
| If yes,
particulars of the Add-on Card - |
| Date
of Birth |
|
| Name
of Add-on applicant : |
________________________________________________________________ |
| Relationship : |
|
|
Spouse |
|
Parent |
|
Major
son/ daughter of
applicant | | |
| |
| I hereby request and authorise you to issue
the above add-on card and I/we shall be
jointly/severally responsible for the use of the
card and payment of the
bills. | | |
| |
| Particulars of Deposits, if any |
| No. _____________ for Rs. ____________ With
___________________ branch of _______________
Bank |
| No. _____________ for Rs. ____________ With
___________________ branch of _______________
Bank | |
| | | |
| |
| Billing |
| I hereby
authorise you to debit my/our SB/CA/OD/CC a/cNo.
______________________ with VIJAYA BANK ___________________
branch as and when the bills are raised. |
| |
| Correspondence & Bills may be addressed to
: |
|
|
Office :
|
|
Residence |
| |
_____________________________________
_____________________________________
_____________________________________
_____________________________________
|
|
_____________________________________
_____________________________________
_____________________________________
_____________________________________
| |
| |
| Other Credit Card Details |
| Issued by (Bank) |
Date Of Issue |
Card Number |
| |
|
|
| |
|
| |
| Declaration |
I/We
confirm that all the information given in this application is
true, correct and complete to the best of my/our knowledge and
belief and hereby authorise the Bank to verify the information
with any source the Bank may consider appropriate. I/We agree
to pay the entrance/annual subscription fees and other charges
which will be fixed by the bank from time to time. I/We have
read/understood and hereby agree to the Terms and Conditions
of this application form. I/We also agree to settle all dues
arising under the VIJAYA BANK Credit Card that may be issued
in my name and Add-on Card that may be issued in the name of
my family members, in accordance with the Terms and Conditions
as existing and as amended from time to time. The use of the
card will be deemed to be acceptance of the Terms and
Conditions.
PLACE :
DATE : |
| |
Signature Of
the Add-on cardholder
(if applicable) |
Signature of
the cardholder
(Applicant)
| | | |