DEBIT CARD ISSUANCE/RE-ISSUANCE FORM

ACCOUNT DETAILS

Account Type : c Savings Account c Current Account

CARD HOLDER DETAILS (Please fill in details only for the holder making the request)

Please paste your passport *

size colour photograph here,

only if you would like a Photo-

card. Do not use pins,

tape, staples to

affix the photograph.

Please paste your passport *

size colour photograph here,

only if you would like a Photo-

card. Do not use pins,

tape, staples to

affix the photograph.

I declare that the above information is correct. I have read the terms and conditions governing the operations of the debit card as part of the general terms and conditions governing my accounts, and agree to be bound by the same, including:

a) The use of the Debit Card is subject to the minimum applicable credit balance available in the Account.

b) The use of the Debit Card shall stand automatically terminated in the event I cease to be an Account Holder(s) or my account is rendered temporarily or permanently non-operational.

Further, I confirm that the attached photograph (if any) against my name, is the present true identity of myself, which I authorize Citibank, N.A., to apply to my Debit Card and for which I accept full responsibility and agree not to make any claim against Citibank, N.A., in respect thereto. I agree to allow ` 200 to be debited from my account per Photo Debit Card requested (if any), as per the applicable schedule of charges which is subject to change from time to time.

(Signature of First Holder) (Signature of Additional Holder)

TERMS & CONDITIONS

I/We, the Account Holder(s), have read and understood the Citibank Account Terms & Conditions stipulated in the Citibank Account Application Form and am/are aware of the Terms & Conditions applicable for use of the Debit Card and agree to be bound by all the Terms & Conditions. I/We agree that the use of the Debit Card shall be as stipulated in the Citibank Account terms and conditions, including:

a) The use of the Debit Card is subject to the minimum applicable credit balance available in the Account.

b) The use of the Debit Card shall stand automatically terminated in the event I/We cease to be an Account Holder(s) or my/our account is rendered temporarily or permanently non-operational.

Date : D D M M Y Y Y Y

Please note: Debit cards are not issued to joint accounts with 'Joint' signature rule.

PRIMARY ACCOUNT HOLDER

ADDITIONAL ACCOUNT HOLDER

(Name to be embossed on the card)

Name :

(Name to be embossed on the card)

Name :

DECLARATION

Reason for Request

c New Issuance c Lost/Stolen c Expired:

c Damaged c Other ________________________

c New Issuance c Lost/Stolen c ExpiredReason for Request

:

c Damaged c Other ___________________

Existing Debit : Card No.

Existing Debit : Card No.

CUSTOMER SIGNATURE (To be signed as per signature rule for the account):

Photo Card Required*

: c Yes c No

Photo Card Required*

: c Yes c No

Citibank A/c No : Branch :

CV/BAN/DBRF/Ver1.5/06-14