Gift Card Application Form
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1Baroda Gift Card Application
To
Date:_________________
The Branch Manager,
__________________________________Branch,
APPLICANT'S INFORMATION
* NAME IN FULL: ____________________________________________________________________________________________
* DATE OF BIRTH/ DATE OF INCORPORATION: _______________________ (dd/mm/yyyy)
* ADDRESS: ________________________________________________________________________________________________
________________________________________________________________________________________________
CITY: ________________________________ STATE: _________________________________ PIN: ____________________
* MOBILE NUMBER: _______________________________ EMAIL ID: _________________________________________________
DETAILS OF ULTIMATE BENEFICIARY
NAME
: _______________________________________________________________________________________________
CONTACT MOBILE NUMBER:___________________________ COMMUNICATION ADDRESS:_____________________________
________________________________________________________________________________________________
PAYMENT DETAIL
CHEQUE
CASH
ACCOUNT DEBIT
ACCOUNT NUMBER SB/ CURRENT/ OD/ CC: _______________________________________________________
I hereby authorize you to debit my account toward the amount to be loaded on the cards and also the applicable card fee.
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Card Amount: ._________________ Fees: ._______________ Total ._______________
Signature of Purchaser/ account holder(s): ______________________________________
_______________________________ _________________________________________
DECLARATION
I/We hereby agree to abide by the terms, conditions, rules, regulations and other statutory requirements applicable to respective prepaid
card. I/We hereby declare that particulars given herein are true, correct and complete to the best of my knowledge and belief; the documents
submitted along with this form are genuine. I/We also acknowledge that as part of purchasing this card, I/We will be visiting Bank’s website
/ Prepaid Card Section for accessing transaction and balance information.
Customer Signature(s) _____________________ ______________ ______________ ________
FOR BRANCH USE
In case of non customer, obtain copy of photo identity and Address proof and keep it along with the application.
URN: ___________________ Last 4 digits of Card: _____________. Card shall be activated within 24 hours from the time of purchase.
Signature of the applicant verified
Entered by:
Authorised by:
I hereby authorize you to debit my account toward the amount to be loaded on the cards and also the applicable card fee.
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Card Amount: .________________________ Fees: ._______________________ Total .______________________________
Signature of Purchaser/ account holder(s): ______________________________________
_______________________________ _________________________________________
ACKNOWLEDGEMENT:
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Received Cash / Cheque/ authority to debit Account for .______________________
Against issuance of : ____________ Baroda Gift Cards vide Application serial No. ______________________ dated _________________
Signature of Branch Official:
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Parent category: Business