Vijaya Bank Credit Cards by aaq20251


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									VI JAYA BAN K
Head Office
Credit Car d Division
41/ 2, M G Road
Bangalore – 560 001
Phone No : 091- 80- 5584066 ( 20 lines)
Telex : 0845 8842 ( VBHO I N)
Fax : 091- 80- 5582915

       APPLI CATI ON FOR V ij a y a I n t e r n a t ion a l V isa Gold Ca r ds
* Please complete the application in full using BLOCK LETTERS
* Tick      where appropriate

                                                 Pe r sona l D e t a ils
                                     ( Please leav e blank space bet w een each nam e)
                                 First Name                           Middle Name                     Surname

Name in full
Name to appear in                                                                              ( m axim um 19 char act er s
Credit Card                                                                                    including space)

Residential address

No                            City                                                       Pincode
Date of Birth                                         (DD MM YYYY)

Sex                        Female             Male

Marital Status             Single             Married

Do you own                 Car                Two Wheeler
                     Registration No : _____________________ Driving License No :
Residence                  Own                Rented ( Monthly Rent Rs _____________ )

No of Dependants ________________________________________________________________________
Income Tax/PAN
Are you a NRI              Yes                No

Passport No          ____________________________________________(Copy to be enclosed)
                                           Em ploym e n t D e t a ils
Service                    Salaried          Self Employed                              Firm/Business/Others
Employed with :      Govt Sector              Advocate               Doctor             Proprietor
                                                                                        Line of Business :
Designation :        Public Sector            CA                     Engineer           Partner
                                                                                        Annual Income Rs.
Length of Service :  Private                  Consultant             Others             ___________________
____________________ Sector

Annual Income Rs.                     Other Income Rs.                        Total Income Rs.
____________________                  ____________________                    ____________________

No                            City                                                 Pincode
Details of Credit Card issued earlier by Vijaya Bank           Yes        No    Particulars

Details of Credit Card issued earlier by Vijaya Bank     Designation :         Branch/Office :

                                            Fin a n cia ls D e t a ils
ASSETS                                                                           LIABILITIES
1. Description & Addressof the        PresentMarket Annual Income From           Details of       Amount
immovable properties                  Value         Immovable properties         business

2. Details of movable properties      PresentMarket Annual IncomeFrom            Details of       Amount
including deposits, shares,           Value         Immovable properties         business
debentures etc.                                                                  liability
                                                 Re fe r e n ce s
References (Other than       Address                            Occupation          Telephone Nos


Enclosed                    Salary Certificate
                            Proof of Business income
                            Proof of other income
                            IT/WT Order

Existing Card Details
Vijaya Bank
                                                                 Expiry Date
 Other Banks
                                                                 Expiry Date
                                                                 Expiry Date

Banking Details (SB/CA/OD/CC/NRE)
Name of the branch VIJAYA
                                                                   A/c No
Other Bank Name & Address                                          A/c No
Other Bank Name & Address                                          A/c No

Particulars of Deposits, if any
No. _____________ for Rs. ____________ With ___________________ branch of _______________ Bank

No. _____________ for Rs. ____________ With ___________________ branch of _______________ Bank
I hereby authorise you to debit my/our SB/CA/OD/CC a/cNo. ______________________ with VIJAYA BANK
___________________ branch as and when the bills are raised.

Correspondence & Bills may be addressed to :
       Office :                                                Residence
       _____________________________________                   _____________________________________
       _____________________________________                   _____________________________________
       _____________________________________                   _____________________________________
       _____________________________________                   _____________________________________

                                                    D e cla r a t ion
I hereby undertake that the International Credit Card (ICC) which may be issued to me by your Organisation
will be utilised strictly in accordance with the Exchange Control (EC) Regulations stipulated by Reserve Bank
of India. I am aware that, in the event of failure on my part to comply with the EC Regulations, I would be
liable for action under the provisions of Foreign Exchange Regulation Act, 1973/FEMA or any other applicable

I confirm that all the information given in this application is true, correct and complete to the best of my
knowledge and belief and hereby authorise the Bank to verify the information with any source the Bank may
consider appropriate. I agree to pay the entrance/annual subscription fees and other charges which will be
fixed by the bank from time to time. I have read/understood and hereby agree to the Terms and Conditions of
this application form. I also agree to settle all dues arising under the VIJAYA BANK Credit Card that may be
issued in my name, in accordance with the Terms and Conditions as existing and as amended from time to


Signature of the cardholder

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