Corporate Office, Plot No.

4,Sector-10
Corporate Office: First Floor,Ansal Tower,
Dwarka, New Delhi-110075
38 Nehru Place, New Delhi-110019
Website: www.pnbindia.in
Email: [email protected]
Contact us: 0120-4616200, 18001802345

CREDIT CARD APPLICATION FORM

Card Type: Rupay Variant: RUPAY SELECT Unique Application Ref. No. (UARN) : MB23000160

Customer's Personal Profile

Name MAYUR PANDURANG PATIL
Name as desired on Card MAYUR PANDURANG PATIL
DOB 12/12/1992 Gender Female
Email ID [email protected] Mobile No. 9137846297
Nationality Indian Alternate Mob. No. -
PAN XXXXXX055G Aadhaar No. / VID XXXXXXXX8381
Educational Qualification Graduate Occupation -
Professional Qualification - Working with -
Marital Status Single No. of Dependent
Father's Name santosh
Mother's Name savita

Spouse Details
Spouse Name
Spouse PAN No. Aadhaar No. -
Spouse Employed or Not N Annual Salary/Income -
Organization Name - Employee No./PF No.

Customer Occupations Details

Staff of PNB / RRB /Others - Employee No./PF No. -
Designation - Scale -
Name of Organization ISG
Place of Posting Date of Joining/Estb 23/08/2023
Posting Since - Duration in Current Org 00:00

Ack/Slip no. ITR / Form 16 / FY/Month Date Gross Taxes Other Statutory Other
Salary Slip Income Deductions Deductions

2/54 Poonawala chawl

City MUMBAI State MAHARASHTRA

Landmark Mumbai Pin Code 400018

Present Residential Address
Period of Stay(In Mobile
months) No.
Residential - Landline -
Accommodation No.
2/54 Poonawala chawl
City MUMBAI State MAHARASHTRA
Permanent Address
Landmark Mumbai Pin Code 400018
Mobile No. Landline No. -
Card Type: Rupay Variant: RUPAY SELECT Unique Application Ref. No. (UARN) : MB23000160

fkfkd

Office Address City MUMBAI State MAHARASHTRA

Landmark fjfjf Pin Code 400013
Mobile No. Office Phone No. -

Communication Address X X ✔

Statement Delivery ✔ X X

Vehicle Information
Name of Vehicle Owner Make Model Reg. No. Type of Vehicle Vehicle Ownership
1
2
3
4
5

Other Banks' Credit Card Detail

Card Limit Issued By
1
2
3
4
5

Details Of Bank Account

Account in PNB N A/c No.
Branch Name Relationship since when
Deposit with PNB Advances/Loan from PNB
Total Deposit with Other Bank Total Advances/Loan from Other Bank

Accounts In Other Bank

Bank Name Branch Name Type of Account Account No.
1 Indian Bank - Savings 1234561235686116
2
3
4

5
Card Type: Rupay Variant: RUPAY SELECT Unique Application Ref. No. (UARN) : MB23000160

Request For Add On Card 1

Name
Name as desired on Card
DOB Gender
Email ID Mobile No.
Relationship Marital Status
Occupation Mobile No.
Request For Add On Card 2
Name
Name as desired on Card
DOB Gender
Email ID Mobile No.
Relationship Marital Status
Occupation Mobile No.

Automatic Debit Mandate No

I Authorize PNB to Debit

Select the option X Total Amount Due X Min. Amount Due

From my PNB’s Account Number

(I hereby confirm to maintain clear balance at the previous day end in my above mentioned account )
Nomination(Rupay Credit Card Insurance Cover)

Credit Card Application

Number. -

Name of Applicant shraddha

Father’s Name of Applicant santosh

Address

District : State: Pincode :

Date of Birth 12/12/1992 Age: 30
Aadhar Number of Applicant XXXXXXXX8381
Bank Account No.(SF/CA/OD) 1234561235686116
Name of Nominee Santosh
Relationship with Nominee Father
Age of Nominee 29
Aadhaar Number of Nominee -

Address of Nominee

State: Pincode :
Name of Guardian (If
Nominee is Minor)
Address of Guardian N.A.
District : State: Pincode :
“I have carefully read and fully understood all the terms and conditions for the eligibility of the claim of
accidental death and permanent disability before signing this nomination form and payment of the claim is
subject to the fulfillment of the terms and conditions of the policy documents/credit cards.”
Card Type: Rupay Variant: RUPAY SELECT Unique Application Ref. No. (UARN) : MB23000160

Normal Photo Aadhaar Photo Gesture Photo

Primary Applicant

Signature

Normal Photo Aadhaar Photo Gesture Photo

1st Add-on Applicant

Signature

Normal Photo Aadhaar Photo Gesture Photo

2nd Add-on Applicant

Signature

PNB Cards & Services Ltd (herein referred to as "PNB Card"), a wholly owned subsidiary of Punjab National
Bank, has its registered office at E-112, 1st Floor, PNB Corporate office, plot no. 4, sector-10, Dwarka, New
Delhi, Delhi 110075, CIN U74999DL2021PLC378579. Email- [email protected], Contact no. 011-28075000.
Card Type: Rupay Variant: RUPAY SELECT Unique Application Ref. No. (UARN) : MB23000160

DECLARATION
1. I/we hereby apply for PNB Credit Card
2. I MAYUR PANDURANG PATIL
________________________________son/daughter of santosh
_________________________applied for PNB Rupay (Platinum/Select) Credit Card. I hereby nominate Santosh
___________________
Father
relationship__________________ for receiving the claim amount of Rupay Personal Accident Insurance and/or Permanent disability cover on Credit Card.
3. I/we consent hereby to exchange the information between PNB and its wholly owned subsidiary-PNB Cards & Services Limited (referred as PNB Card) with each other
4. I/we hereby declare that information shared with Bank Staff/Representative of its Subsidiary is complete and true and PNB/ PNB Cards & Services Limited is entitled to verify this
directly or/and through any outsource agencies/ third-party agents.
5. I/we understand that PNB Cards & Services Limited is a wholly owned subsidiary of the PNB for doing non- financial support services which includes but not limited to acquisition of
credit card application of PNB and the sanction/decline and further management of card and card related issues shall be solely managed by Punjab National Bank.
6. I/we authorize PNB to debit my/our credit card account for any fees, charges, interest, etc. The usage of the credit card/s by me/us will also be deemed to be automatic confirmation
of the acceptance of the said terms and conditions. I/we will be liable to comply with the rules of the Foreign Exchange Management Act 1999 and the amendments thereof as
stipulated by the Reserve Bank of India. I/we undertake to intimate PNB and surrender our credit cards before proceeding overseas on permanent employment and/or emigrating
and/or changing my/our nationality.
7. I/we authorize PNB to share details of my/our card transactions with other card issuers and/or financial institutions and/or other entities as PNB may deem fit. I/we acknowledge that
PNB remains entitled to assign any activities to any third party agency at its sole discretion. I/we authorize and hereby give consent to PNB to provide details of my/our account to
third party agencies for the purpose of processing, issuing,marketing and management of all activities relating to Credit card. "In addition to any general right to set-off or other
rights conferred by law or under any other agreement". I/we authorize PNB to, without notice, combine or consolidate the outstanding balance on the card account with any other
account(s) which I/we maintain with PNB and set-off, transfer any money outstanding to the credit of such other account(s), In or towards the satisfaction of my liability to PNB under
this Agreement I also authorize PNB and its subsidiares to send me SMS Alerts on marketing/ account related Information on my mobile phone number.
8. I hereby authorize PNB and PNB Cards & Services Limited to use my Aadhaar Number and / or biometric / demographic information to verify my details from UIDAI. I understand that
PNB and PNB Cards & Services Limited will be calling for data from UIDAI and the same will be stored with PNB and PNB Cards & Services Limited for providing me the product /
services opted by me. PNB and PNB Cards & Services Limited will maintain confidentiality of the same.
9. I, the primary card holder, acknowledge that the credit card limit approved on my account is to cover all transactions whether made by me or add-on card holders (now added or
subsequently added). I/we will be responsible for any transaction/ usage of card made i.e. withdrawal from ATM, payment and other transactions through ATM, purchase from
Merchant Establishment by me/add-on card holder/s and even by anyone else by misuse or use permitted by me or add-on card holder, of the card Issued to me or to add-on
cardholder/s. I, as primary card holder, will be liable for all transactions of mine as well as add-on card holder/s
10. I/we, understand that as a pre-condition, relating to grant of the loans/advances/other non-fund based credit facilities to me/us, PNB requires my consent for the disclosure by PNB of
information and data relating to me/us, obligations assumed/to be assumed, by me/us, in relation thereto and default in any, committed by me/us, in discharge thereof:

a. Accordingly, I/we, hereby agree and give consent for the disclosure by PNB of all or any such : (i)Information or data relating to me/us (ii) the information or data relating to any
credit facility availed of/to be availed, by me/us and (iii) default, if any committed by me/us, in discharge of my/our such obligation, as PNB may deem appropriate and necessary, to
disclose and furnish to Credit Information Bureau (India) Ltd. and any other agency authorized in this behalf by RBI in terms of Credit Information Companies (Regulation) Act 2005.

b. I/we undertake: (i) the Credit Information Bureau (India) Ltd. and any other agency so authorized may use, process the said information and data disclosed by PNB and (ii) the
Credit Information Bureau (India) Ltd. and any other agencies so authorized may furnish for consideration, the processed information and data or products thereof prepared by them,
to Banks/financial institutions and other credit guarantors, as may be specified by the Reserve Bank in this behalf.

c. I/we hereby agree and give consent to the Bank to modify the rate of financial charges at its sole discretion from time to time without any prior information and levy such charges
accordingly.

d. The applicant agrees and confirm that the Bank will always be at liberty to stop making advances or cancel the credit facility(ies) at any time without prior notice and without
assigning any reason, even though the credit limit(s)/ credit facility(ies) has/have not been fully availed of.

e. I/we confirm having received and understood the PNB’s Credit Card Terms and Conditions supplied to me which I/we unconditionally accept and also the changes brought out from
time to time.

f. I/we further authorize PNB to use the personal information provided for cross selling the product with its subsidiaries or other agencies/entities.

g. I/we confirm having read and understood the recent terms and conditions including Most Important Terms and Conditions (MITC) supplied to me which I/we unconditionally accept
the same.

h. I/we authorize PNB and its subsidiaries to use Aadhaar number/VID number, PAN, TIN and other information/details provided by me/us to collect/verify information/details from
Unique Identification Authority of India (UIDAI), National Securities Depository Limited (NSDL), Income Tax and/or any other government body or authorities. I/we understand that
PNB shall be relying on the information received from UIDAI and/or any other government body for processing credit card Application.

11. For card issued to me against my fixed deposit, I hereby give my consent for the following: (a)I request you to mark your lien on the fixed deposit mentioned above. The deposit may
be renewed for a similar period on the date of maturity so as to allow continuity of my credit card which will expire after a period of three/five years from the date of issue of credit
card. (b)I/we hereby declares that I/we have not created/shall not create any charge/lien or other emcumberance upon or over the above mentioned deposit or ny thereof. (c)I/we
further authorize PNB to exercise the right of set-off, irrespective to the maturity date, on all monies, securities, deposits belonging to me/us or standing in my name, in case of
monthly credit card dues are not paid on expiry of 60 days of "payment due date". (d)I/we undertake that deposit held with bank will not be withdrawn during period for which credit
card is held.

Primary Applicant Signature First Add-on Applicant Sign. Second Add-on Applicant Sign

Branch User PF No. :1234568

Branch User name : Shraddha Joshi

Date : 23-Aug-2023 PSA ID/Agency Code : PNB

Place : Mumbai Signature : MAYUR PANDURANG PATIL

Signature

PNB 1263