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					ICICI Bank Ncash Debit Card Application Form

Applicant Name: ________________________ First Name

Middle Name

Last Name

I am an existing savings / current account holder of ICICI Bank and hold an ATM card linked to my account. I would like to link my account number ____________________________to my Debit card. I confirm that I am the sole account holder. (In case of multiple accounts, the Account number listed above will operate as the primary account linked to the Debit card.) I / We authorize ICICI Bank Ltd. to issue an ICICI Bank Debit cum ATM Card to me/us in lieu of an ATM Card. I / We acknowledge that the issue and usage of the Card is governed by the terms and conditions as in force from time to time and agree to be bound by the same. I / We acknowledge that it is my / our responsibility to obtain a copy of and read the same. I / We accept that the terms and conditions are liable to be amended by ICICI Bank Ltd. from time to time.

I / We understand that upon issue of a Debit card to me/us, the existing ATM card linked to my / our account will be deactivated. I / We further unconditionally and irrevocably authorise ICICI Bank Ltd. to debit my / our Account annually with an amount equivalent to the fees and charges for use of the Debit Card.

Date ____________________ ______________________________ 1 1st Account holder's Signature __________________________________ 2nd Account holder's Signature

(In case of joint account holders, both account holders shall put their signatures authorising the 1st applicant to operate their account through the Debit Card) FOR BANK USE Branch: _______________________ Date: ______________________

Signature/s Verified by Bank Officer: Account Number Allotted: Cust-ID Allotted:

_________________________________________ _________________________________________ _________________________________________

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