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| Primary Holder |
| ____________________________________ |
| Name
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I confirm that the attached photograph is the present true identity
of myself, which I authorize Citibank, N.A., to apply to my ATM/Debit Card
and for which I accept full responsibility and agree not to make any
claim against Citibank, N.A., in respect thereto. And that this condition
applies in addition to the terms and conditions which govern the use
of my ATM / Debit Card. I agree to allow Rs. 500/- to be debited from
my Citibank Suvidha Account for the Photo ATM/Debit Card requested by me.
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| ATM/Debit
Card No.: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
(16 digits) |
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| Signature
: _________________________
Date: |__|__|
|__|__| |__|__|__|__|
(dd
/ mm / yyyy) |
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| Joint
Account Holder |
| ____________________________________ |
| Name |
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I confirm that the attached photograph is the present true identity
of myself, which I authorize Citibank, N.A., to apply to my ATM/Debit
Card and for which I accept full responsibility and agree not to make
any claim against Citibank, N.A., in respect thereto. And that this
condition applies in addition to the terms and conditions which govern
the use of my ATM/Debit Card. I agree to allow Rs. 500/- to be debited
from my Citibank Suvidha Account for the Photo ATM/Debit Card requested
by me.
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| ATM/Debit
Card No.: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
(16 digits) |
|
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| Signature
: _______________________
Date: |__|__|
|__|__| |__|__|__|__|
(dd
/ mm / yyyy) |
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| Citibank Suvidha
A/c No.: |
|__|__|__|__|__|__|__|__|__|__|
(10 digits) |
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Rush this form to :
Citibank Suvidha
Anna Salai P.O.,
Chennai -600002
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