Customer Request Form.cdr

Customer Request Form (* Fields are mandatory)

Branch

The Branch Head

DCB Bank Limited

YYYYMMDD

Date:

*Account No.:

*Customer ID:

Customer Name:

Mr. Mrs. Ms. M/s.

(First Name) (Middle Name) (Last Name)

Dr.

Prof.

DCB Bank Limited

Note: All support documents or proofs should be “Self Attested”

Update Contact Details (Please Tick the Appropriate Box)

Change of Address:

City:

Pin:

Signature

Note: Kindly provide proof (For Individuals - applicable for accounts less than 6 months old and for Entities - address proof is mandatory) of the new mailing address along with this form.

Please note address will be changed only for the primary customer ID in all the linked accounts. All the other holders in the account have to submit separate address change request.

Landmark:

State: Country:

STD Code

2. Update of Other Details :

Change of Mobile Number

New Mobile Number:

Change of Telephone Number

New Telephone Number:

Change of Email ID New Email ID:

+ 9 1

Update my PAN Number PAN Number:

(Copy of PAN card required, it should

be self-attested)

New email

address will

be updated

only in the

account number

mentioned

above

*My Occupation:

*Occupation Code:

Please affix

a recent

photograph

Sign across the photo

(Applicable to point No. 8

on ISA updation only)

Mobile number

will be

automatically

registered for

SMS Alerts.

You will receive

any Bank related

promotional

calls, SMS alerts

Note: *Authorised signatory/ies of the Firm / Company / Trust / Association / Society are eligible for free Mobile alert facility subject to compliance of terms and conditions as stipulated by

the Bank from time to time.

Update my Aadhaar Number Aadhaar Number:

(Copy of Aadhaar card

required, it should be

self-attested)

Tracker Reference No.:

Communication Permanent Both (Communication and Permanent)

Signature

Registration Details (Please Tick the Appropriate Box) I wish to apply for following service/s

Phone Banking *Your Mother’s Maiden Name:

Internet Banking

E-statement Registration *Email id:

Frequency of E-statement:

SMS Alerts

Note: *Authorised signatory/ies of the Firm / Company / Trust / Association / Society are eligible for free Mobile alert facility subject to compliance of terms and conditions as stipulated by

the Bank from time to time.

Mobile Number:

Mobile Banking Registration Please fill a separate Mobile Banking Registration Form for Joint Account Holder

+ 9 1

Daily

(for current account only)

Weekly

(for current account only)

Monthly

(Kindly attach Declaration where internet banking request is from Minor)

Email id needs

to be mentioned

for Internet

Banking

Preferred Language Options: English Hindi Marathi Gujarati Tamil Telugu

Activation Deactivation2-Way Sweep Deposit Details:

Please Note: Reverse Sweep to Fixed Deposit account shall happen only, if the balance in the account exceeds threshold limit and Sweep shall happen if the balance in the account goes below

the threshold limit. All deposits will be under Re-investment scheme with Auto Renewal Facility, this facility may differ from product to product and from time to time.

Oriya Punjabi

Yearly

Link Aadhaar Number to Account Number

DCB 24-Hour Customer Care

Call Toll Free: 1800 209 5363

Email: [email protected]

Web: www.dcbbank.com

Acknowledgment to Customer

We acknowledge receipt of ‘Customer Request Form’ from _______________________________________________________________________________ (customer

name) on __________________________ for ______________________________________________________________________________________________________

Name of Branch Official: _______________________________________________

(Signature of Branch Official with Seal)

M008 / Jan 16 / 1.2

Terms & conditions: I agree to discontinue the physical statements being sent to me. I understand that the email statements are for my convenience. DCB Bank Limited (the “Bank”) shall not be liable or responsible for any breach of

secrecy because the statements are being sent to the above email ID. I shall verify the authenticity of the emails I receive. I shall not hold the Bank responsible for any statement received from fraudsters / imposters. I shall not hold the

Bank liable if any problem arises with my computer network because of me receiving statements from the Bank. I have been authorized by the other holders to receive the statements on the above email address. I shall immediately

inform the Bank in writing if there is any change in the information given above. The Bank shall not be responsible if I do not receive statements due to incorrect email address and technical reasons. I confirm to have read and

understood the terms & conditions pertaining to my account. This registration will override any “Hold Statement” facility availed in the past.

Request (Please Tick the Appropriate Box)

1. New Cheque Book Request Number of Cheque Leaves required:

4. Pass Book (please issue)

Account Activation (Activation of Dormant Account)

Reason for not operating account

(Attach ISA for Dormant Account and where KYC is incomplete)

Signature

10. Account Related Queries: Cheque Book not received Debit Card not received

Debit Card PIN number not received Fixed Deposit Receipt (FDR) not received

Signature

12. Internet Banking: Pin not received User ID not enabled Duplicate Password issue

Signature

Statement required from date

YYYYMMDD

Statement of Account / Duplicate Statement

Limit of cheque

book issuance

would be as

per the product

feature

3. Consolidated Statement of Account (Applicable for all your accounts)

8. ISA Updation Proof Submitted:

9. Reversal of Charges

I undertake to henceforth keep an Average Quarterly Balance of `

Date of Debit:

YYYYMMDD

Amount of Debit `:

to honour cheques issued by me

13. Other Requests Specify

Maximum 19

characters. The

name would

appear on

the Card.

Change Mode of Operation (Individual accounts only) for Account No.

Declaration

I have read and understood the Terms & Conditions relating to various services offered by the Bank. I am aware of charges applicable for various services offered and I accept and agree to be bound by the said Terms & Conditions.

The terms and conditions for these services are available on the Bank’s website www.dcbbank.com. I further authorize the Bank to debit my Account towards any applicable charges for any / various service / services provided as

applicable from time to time. I understand that in the event of me already being registered for Phone Banking / Net Banking, this application will be treated as an authenticated request for regeneration of my TPIN/IPIN. I agree that the

Bank may debit my account for service charges as applicable from time to time. I agree to adhere to all the terms and conditions of opening / applying / availing / maintaining / operating (as applicable) for usage of mobile banking

service of the Bank as may be in force from time to time. I hereby expressly consent and authorise the Bank to make telephone calls, send SMSs or emails, IVR to voice out and enable Mobile Banking to inform / benefit me on any

information or updates relating to the Bank’s existing / new products / services / account information including SMS when a Pull SMS is sent. I agree and understand that by agreeing to receive the Statement(s) via E-mail under the

option ‘Go Green declaration box’, I have at my own discretion accepted that such Statement(s) shall not be sent to me separately by post or in physical form, through whatever other means.

*I understand and agree that the consent given for updation / registration / requests for free Mobile alert facility shall be valid till such time I withdraw the same in writing. Unless specifically advised, the Bank will continue to send SMS

alerts on the number requested by Authorised signatory/ies of the Firm / Company / Trust / Association / Society.

The Bank shall not be responsible and liable for any consequences which may arise owing to change in name/s of authorized signatory/ies or partners or directors or trustees or members of the Firm / Company / Trust / Association /

Society.

I confirm that all the details provided in the form are correct.

Name:

Date: Customer Signature

YYYYMMDD

For Bank Use Only

Customer request acted upon on

YYYYMMDD

/ forwarded to

On Relevant charges debited `

Name of the Branch Official:

Signature of Branch Official with Seal

YYYYMMDD

o I confirm that the account status is active and signature of the customer matches with our records.

I have verified the o Current Address o Mobile Number o Email address of the customer and confirm it to be right as per our records

DCB Bank Limited243-Ver 1.0-Apr 2013

Attach

DOB Proof

6. Senior Citizen Updation: Date of Birth

YYYYMMDD

Debit / ATM &

Rupay / Visa

card will be

issued as per

product feature

New International Debit Card

Debit Card hotlisting Debit Card Number:

Reissue of Card Reason

Issue of Duplicate Pin of Debit / ATM Card

Short Name:

11.

New Debit card Short Name:

New ATM card Short Name:

Self Jointly Either or Survivor Former or Survivor Guardian

¨ Rupay

¨ Visa

¨ Rupay

¨ Visa