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(Wholly Owned by Govt. of India)

P.C. No. 36 -015 Individuals/Joint/Sole Proprietorship A/C


CIF No (9 Digits) :

I, Mr/ Ms. ____________________________________(“USER”), S/o D/o, W/o ________________________________________ wish to apply for the following services from INDIAN BANK. (Please Tick whichever is required) Occupation: Internet Banking Date of Birth: Phone Banking Mobile Banking (Unique Mobile No. mandatory) Res:_______________________________________________________ ________________________________________________________ ________________________________________________________ _______________________________________________________ PIN CODE: _____________ __________________________ *Mobile No:_______________________________

Address Off. : _________________________________________________ _________________________________________________ _________________________________________________ ________________________________________________ PIN CODE: _____________ _________________

Fax No. : ______________( if FAX statement Required) PAN No:______________________ Name of the cellular service provider: City/Town: E-mail Address : ___________________________@_______________________

The following accounts maintained in your branch/other branches of your Bank, may please be linked under the IndiaNetBank service. S.No Branch Name Account Number (s) Account Type SB/CA/TD Mode of Operations E or S/ A or S / Joint

1. 2. 3 4

For availing the internet facility • I note to maintain minimum balance stipulated. I am agreeable to pay charges as fixed by the Bank. I also note that if primary account designated by me is closed, I will have to forego the Internet Banking facility. • I authorise Indian Bank to debit my account No. ________________ at __________________branch towards the related charges ( OR ) I enclose cheque /draft no for Rs. Payable to Indian Bank a/c IndiaNetBank towards charges. In case of JOINT ACCOUNT HOLDERS: I am authorised to avail the Internet services individually in respect of accounts held in joint names, for which I enclose the mandate from the other account holder(s) I have read, understood and I agree to abide by the terms and conditions governing Internet Banking services. Once my request for IndiaNetBank account is accepted and my user ID is activated by the bank, all my linked accounts (including any new accounts that may be opened with my customer ID subsequent to the issue of IndiaNetBank account User ID and password) will be covered under the rules governed under IndiaNetBank account from time to time. Date : __________________ INSTRUCTIONS FOR FILLING THE FORM 1. 2. 3. Please mention the CIF No (9 digits). The CIF No (9 digits) of the user will be the user –id for the Internet Banking Services. * Mobile No is compulsory in case of customer is availing Mobile Banking

SIGNATURE ________________________________

(Wholly Owned by Govt. of India)

For office use only
The request of Customer _______________________________________ (NAME) for the services requested may be enabled. Signature of the Branch Manager. CUSTOMER NO IS : ___________________________________ 1) The mode of operations for all his declared accounts have been verified and found Correct. 2) Signatures of Joint holders have been verified and found Correct 3) The users have been enabled for Internet Banking 4) 5) Phone Banking Mobile Banking (Unique Mobile No. mandatory)

The user has been informed that only after acknowledgement of PIN MAILER, his/her account can be activated. The user has been informed to acknowledge the receipt of Pin mailer to CDC Directly by Mail or Through Branch.

INFORMED TO CDC on ____________________(DATE) RECORD FORMED PART OF THE FILE _________________________________( FILENAME)

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