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Basic Details Information

Title MR
First Name
PR~
Middle Name Nf\R~Pr-N
Last Name ,t \S.rtt.0~~ "', 'KM f\
Name to be embossed on Card PRc..-M \S\'\ tDf\-~'\R.C".t A.
Date Of Birth 0\ o.S- r l.988
Gender '
Mobile _q ~2G G,g 2-3 0
Work Type SftL#\-R\ en
Pan no ~.:r~f'\J~GGt F-
Email id ~ ' - i \S\-\wA;~f\~,c<\ Pt 01.. @ '{C<tF\l L • CL!>-~
Residential.Address
Address line 1
Address line 2
G, Address Hne 3 -
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r City 0-\~ 1-\-fs.~
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slJ State t)~ t\R._,;\;-"i

Postal·code 38001
.:::) Country J:~DtA
0 Residence Type
Years/Months in Current Address

Address line 1
Address line 2
Address line 3

1
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1-C_it-=--y-----------+--------------------------~
State

Postal ,ode

Address line 2 C e.
Address line 3
City
State
Postal code
Country
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Card Mailing Address . . . ~- Residence D Permanent

Additional data Information

Nationality

Country Of Birth

Country Of Residence

Educational Qualification P'·G

Occupation

GSTNo

Marital Status

Place of Birth

Spouse name

Mother 's name

Home no

Office no {At fh-t~ ('tf>: . 90936 \\l\~'

Office Emai~

Office Extension

.company name

Company Type

Total Experience

Year's in Current Organisation

\G L~

Platinum Rewards Super Value Titanium 9,ltimate

·Manhattan Platinum

First Year Free

Sourcing Details

DSR ID- R

DSRID-C

DSRID-S
 DECLARATION - CREDIT CARD APPLICATION

Credit Card Application Number

111111111111111

I <N_ame of the Applicant Pf?S:M ~frP.A-~ "IS.HW~~R.Mfl:. ("I", "you", "my" or "your") have
applied for a Standard Chartered Bank credit card as per the selection below:

(Please tick the appropriate boxes)

D Ultimate efsuper Value Titanium

D Emirates D Platinum Rewards
D Priority Visa Infinite D DigiSmart
D Premium Super Value Titanium D Others -------
D Manhattan Platinum

I, the undersigned:

l. represent and warrant that all information (including any documents) I have given to Standard Chartered
Bank ("Bank" or "us") in connection with the application is correct, complete and not misleading (lfthis is
not the case I may be personally liable,;
2. authorize the Bank to verify any of the infonnation I have given to· the Bank or my credit standing from
anyone the Bank may consider appropriate (such as an authority or credit reference agency or credit bureau);
3. authorize the Bank to authenticate any credit card details I give the Bank by conducting test authorizations
with the issuer of that credit card;
4. acknowledge that the Bank may decline my application. If this happens, no contractual relationship will arise
between me and the Bank, and the Bank reserves the right to retain the documents I have submitted with the
application;
5. confirm and agree that the Bank may give any information in connection with this application (including my
personal information) to any service provide (whether located in or outside if India) for the purpose of
pro.vid-ing any service to me in connection with this application (including data processing) or credit card
product features;
6. agree that I will inform the Bank when there is any change in my address, occupation, employment or status
ofmy residency in India. If the B-ank asks, I w.U also give the documents to prove such a change;
7. consent to- ~acl:i.of·Standard Chartered Group and its subsidiaries and affiliates (including each branch or
representative office) ("Standard CharteFed Group") its officers, employees, agents and advisers disclosing
information relating to me (including details of the accounts, products or any security interest) to:
its head office and any other member of the Standard Chartered Group in any jurisdiction ("permitted
parties");
• professional advisers, service providers or independent contractors_ to, or agents of, the pem1itted
parties., such as debt collection agencies, data processing firms and correspondents who are under a
duty of confidentiality to the permitted parties;
any actual or potential participant or sub-participant in relation to any of our obligations under our
baking agreement between us, or assignee, novatee or transferee (or any officer, employee, agent or
adviser or any of them);
any credit reference agency, rating agency, business alliance partner, insurer or insurance broker of or
direct or indirect provider or credit protection to, or any permitted parties;
 • any court, tribunal or authority (including an authority investigating an offence) with jurisdiction over
the permitted parties;
• a merchant or a member of a card association (for instance, Visa or Master Card) where the disclosure
is in connection with use of a card;
• any authorised person or any security provider;
• anyone the Bank considers necessary in order to provide me with services in connection with an
account;
• domestic or overseas regulators or tax authorities where necessary to establish my tax liability in any
jurisdiction pursuant to orders, agreements with regulators or authorities or otherwise.
8. declare that all foreign exchange transaction entrusted to the Bank from time to time do, not involve and are
not designed for the purpose of any contravention or evasion of the provisions of the Foreign Exchange
Management Act, 1999 or any rule regulation, notification, direction or order made under that Act. I also
agree to give the Bank any information or document as will satisfy the Bank about the purpose of a
transaction. I also understand that if I do not fully comply with any requirement, the Bank can refuse to
under-take a transaction and may report the matter to RBI. Relying upon this declaration, the Bank may not
insist on me giving specific further declarations for future foreign exchange transactions;
9. confirm that no insolvency / bankruptcy proceedings have been initiated against me nor have I ever been
adjudicated insolvent;
10. confirm that I have read, agreed to and understood the Bank's Client Terms and the applicable documents
referred-to.in-Part-A of the Client Terms and the Credit Card terms forming the banking agreement which are
available as part of the electronic application journey as a PDF, at any of the Bank' s branches or on the
Bank's website at www.sc.com/in and I agree to be bound by the same. I acknowledge that I am bound by
any variation the B'lmk makes to these documents, in accordance with the banking agreement. In particular, I
understand that by entering into the banking agreement I give indemnities, authorizations, consents and
waivers and agree to limitations on the Bank's liability;
11 . have authorized <name of empl"oyee >, an employee of the Bank having
employee ID <employee ID > or Sales Agent namely <Name of Agent >
to enter the details in the electronic application form on my behalf, as per the instructions _given by me;
12. have reviewed and verified the details entered by him / her in the electronic application form before they were
submitted and declare the same to be true, correct and updated;
13. confirm that the electronic application form and this declaration form shall together constitute the application
fom1 for the above referred credit card;
14. confirm that I have read, understood and accepted the declarations, which form a part of the online application
form, before the application details. were submitted;
15. confirm that I have read, understood and accepted the Important Information Document, which forms a part of
the online applicati-on foffll, pertaining to the credit card that I have applied for and understand that I shall
receive a copy of the same by way of email on the registered email id.
16. understand that the Bank will disclose the status of my application for the product to the sales agent or entity
through whom J have submitted my appli~ation.
17. agree and accept· an claims and disputes arising OJ.!t of or in connection with the credit card shall be setded by
arbitration-in accordance with the provisions of the Arbitration and Conciliation (Amendment) Act 2015 and
any subsequent statutory amendments if any to the said Act, by a sole arbitrator to be appointed by the Bank,
except where such claim or dispute faHs within the jurisdiction of the Debt Recovery Tribunal established
under the Recovery of Debts due to Banks Due to Banks. and Financial Institution Act, 1993 . Any arbitration
award or direction passed shall be fina~ and binding on the parties. The language of the arbitration shall be
English, and the venue of such arbitration shall be at Mumbai. ·
18 . agree that the electronically executed application form and the terms and conditions governing the credit card
(s) and/or services I have applied for may be sent to me by email and I agree tl'.iat I will not dispute the
validity, admissibility and enforceability of such terms and conditions only on the basis they are in electronic
form .
19. For Non-Resident Indians/ Persons oflndian Origin (PIO) Declaration
have met/spoken to the concerned relationship manager of Standard Chartered Bank in India, and confirm
2
 that I will be executing transactions during the course of our stay in India and in due compliance with
applicable local laws and regulations and if I execute any transactions from our country of our residence, I
confirm that the same would be in due compliance with the applicable local laws and regulations in my
country of residence.
20. Aadhaar Declaration

(Please tick the appropriate boxes)

I want to open a credit card account with Standard Chartered Bank, India ("Bank") and I have been infonned by the
Bank that (a) it is not mandatory for me to submit my Aadhaar number; and (b) there are other alternate and viable
means of identification. However, in spite of the availability of other alternate and viable means to establish my
identity, I hereby consent to and voluntarily submit my Aadhaar number (in physical) to the Bank to establish my
identity or in such other fonn as may be notified by the government, UIDAI or under any law, for the purpose of
establishing an account-based relationship with the Bank in my name

Name of Client: "Rec<\ Nf\"-Rfy"(lftN

Signature of Client:

Date:

Photo

3
SPECIMEN SIGNATURE:

ELECTRONIC APPLICATION FORM DECLARATIONS

I I We have applied for a Standard Chartered Bank

(Please tick the appropriate boxes)

savings account _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (variant)
D

/ credit card _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (variant)

personal loan _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (variant)

D
numberwhich was generated
vide application
upon I /we
reference
I I IeJ :tl Pl 1~1°1. I I I I I I I I
clicking the "Submit" button at the end of the electronic application form.

I / We, the undersigned, declare, confirm and agree:

1. · That I/ we have authorized f't~\j~ Q-~~()t\'-9 € C°)\ an employee
of Standard Chartered Bank having employee ID ;:cf) to enter the details in the electronic
application form on my/ our behalf, as per the instructions given by me.
2. That I I we have reviewed and verified the details entered by him I her in the electronic application form before
they were submitted and declare the same to be true, correct and updated.
3. That the electronic application form and this physical confirmation form shall together constitute the application
form for the above referred products.
4. That I I we have read, understood and accepted the declarations, which form a part of the online application form,
before the application details were submitted.
5. That I I we have read, understood and accepted the applicable terms and conditions which are available on the
Bank's website www.sc.com1inand I I we agree to be bound by them.
6. That I / we have read, understood and accepted the important information document, which forms a part of the
online application form, pertaining to the
(Please tick the appropriate boxes)

~ credit card
D personal loan

that I I we have applied for and understand that I / we shall receive a copy of the same by way of email on the
registered email id. My / Our signatures below are a confirmation of the same.

Applicant Name: f'f<C.-{'(\ fr-f<-J\-'t

Applicant Signature: ______~-'-----::,,,,-,:;;.----'-..i.t_ _ _ _ _ _ _ __