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 International Visa Gold Cards * Please complete the application in full using BLOCK LETTERS * Tick where appropriate   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 (maximum 19 characters including space) Residential address   Tel/Fax No City Pincode Date of Birth (DD MM YYYY) Sex Female Male Marital Status Single Married Do you own Car Two Wheeler   Registration No : _____________________ Driving License No : ___________________ Eductional Qualification ________________________________________________________________________ Residence Own Rented ( Monthly Rent Rs _____________ ) No of Dependants ________________________________________________________________________ Income Tax/PAN No ________________________________________________________________________ Are you a NRI Yes No Passport No ____________________________________________(Copy to be enclosed)

Employment Details Service Salaried Self Employed Firm/Business/Others Employed with : ____________________ Govt Sector   Advocate Doctor Proprietor Line of Business : ___________________ Designation : ____________________ Public Sector CA Engineer Partner Annual Income Rs. ___________________ Length of Service : ____________________ Private Sector Consultant Others   Annual Income Rs. ____________________ Other Income Rs. ____________________ Total Income Rs. ____________________ Office/Business Address   Tel/Fax No City Pincode 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 IT/WT Order   Existing Card Details Vijaya Bank 1.   Expiry Date __________________________   Other Banks 1.   Expiry Date __________________________ 2.   Expiry Date __________________________   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     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   _____________________________________ _____________________________________ _____________________________________ _____________________________________   _____________________________________ _____________________________________ _____________________________________ _____________________________________     Declaration I hereby undertake that the International Credit Card (ICC) which may be issued to me by your Organisation will be utilised strictly in accordance with the Exchange Control (EC) Regulations stipulated by Reserve Bank of India. I am aware that, in the event of failure on my part to comply with the EC Regulations, I would be liable for action under the provisions of Foreign Exchange Regulation Act, 1973/FEMA or any other applicable act. I confirm that all the information given in this application is true, correct and complete to the best of my knowledge and belief and hereby authorise the Bank to verify the information with any source the Bank may consider appropriate. I agree to pay the entrance/annual subscription fees and other charges which will be fixed by the bank from time to time. I have read/understood and hereby agree to the Terms and Conditions of this application form. I also agree to settle all dues arising under the VIJAYA BANK Credit Card that may be issued in my name, in accordance with the Terms and Conditions as existing and as amended from time to time. PLACE : DATE :   Signature of the cardholder (Applicant)