Debit Card Application Form DECLARATION
I would like you to issue me a Standard Chartered Debit Card. I / We confirm that the information furnished by me / us in this application is
My full name: true and correct to the best of my / our knowledge and belief. I / We have
First Name: read and consciously understood the terms and conditions applicable to the
operation and conduct of Standard Chartered Debit Card to be
maintained by me / us with you. We undertake to strictly utilise the card in
Middle Name:
accordance with the Exchange Control Regulations as laid down by
Reserve Bank of India from time to time. In the event of any failure on our part
Last Name:
to comply with all or any of the guidelines laid down by Reserve Bank of India,
Standard Chartered Bank,Government of India or any other duly
E-mail : constituted regulatory body or authority, we irrevocably agree to forfeit all our
rights to this Debit Card and further agree to be debarred from holding and
Tel.No.: Office : Res.:
utilising the Standard Chartered Debit Card at the instance of either Standard
Date of Chartered Bank or Reserve Bank of India or both. I / We hereby irrevocably
Mobile:
Birth authorise you to furnish the details of all or any of the
transactions to Reserve Bank or any other authorised dealer of foreign
Occupation:
exchange or any person duly constituted for this purpose, as you may deem
My name, as it should appear on the card : (Please leave one blank space between each name) fit and proper without obtaining our oral or written prior consent from me / us.
I / We presently am / are a citizen of India , hereby irrevocably agree to
inform Standard Chartered Bank and undertake to return and surrender the
said Debit Card before emigrating from India, whether permanently or
My Primary A/c No.:
otherwise, for employment or owing to change in citizenship / nationality
I would like to link the following additional accounts with my Debit Card. or otherwise.
Account 1: I / We am / are a citizen of _______________________, and / or non-resident
Indian , hereby undertake to inform Standard Chartered Bank in the event
Account 2: of change in my / our domicile status.
Please issue me (please ✓ one) : Annual Charges on Debit card*
Shop Smart Debit Card Platinum Debit Card SME World Debit Card** Shop Smart 220
Platinum Debit Card 799
Priority Banking* Preferred Banking* Breeze Banking Debit Card Breeze Banking Debit Card* 499
Cash Back Platinum Debit Card Others _________________________ Cash Back Platinum Card 499
*Preferred and Priority Card can be applied by the customers who fall under this SME Debit Card Free
segment only. Preferred Banking Debit Card Free
** SME World Debit Card will be issued only to SME non individual customers. If Priority Banking Debit Card Free
you have selected this option please provide the mandatory details below:
**Preferred Company name as it should appear on the SME World Debit Card: *The personalization charges are not included in the above mentioned charges
I / We confirm having read and consciously understood the bank’s tariffs for
the Debit Card and hereby agree and undertake to be bound and abide by
Maximum of 15 characters only. Please leave a space between two words the same as may be enforced upon me by the bank from time to time.
Preferred Daily Card limit in INR for SME Debit Card (Please select one)
I / We confirm that the foreign exchange which will be used will be within the
10,000 50,000 1 Lac 2 Lacs 3 Lac 5 Lacs
limits of Business Travel Quota as per Foreign Exchange Management Act,
__ Applicable for SME World Debit Card only
1999. I / We will adhere to guidelines which are issued by the Reserve Bank
Debit Card can be issued to all account signatories (as confirmed in the Board Resolution) of India concerning use of Foreign Exchange.
Please provide details of Additional Card holder in Additional Card Section Below
Additional Card In the event of any default committed by me / us of any of the aforesaid
guidelines, terms and conditions or any law of statute, I / We shall indemnify
Please provide details of Additional Account Signatory if a Card is required. the bank of any loss or damage that may be caused to it.
Card Holder’s Name :
For Primary Account :
First Name:
Middle Name: Name : _____________________________ X __________________________________
Signature of primary account holder
Last Name:
Tel.No.: Office : Res.:
Name : _____________________________ X __________________________________
Date of Signature of primary account holder
Mobile:
Birth
Occupation:
Name : _____________________________ X __________________________________
My name, as it should appear on the card : (Please leave one blank space between each name) Signature of primary account holder
For Linked Accounts:
(Joint Account holders other than applicant)
My Primary A/c No.:
I would like to link the following additional accounts with my Debit Card. Name : _____________________________ X __________________________________
Signature
Account 1:
Account 2: Name : _____________________________ X __________________________________
Please issue me (please ✓ one) : Signature
Shop Smart Debit Card Platinum Debit Card SME World DebitCard**
Priority Banking* Preferred Banking* Breeze Banking Name : _____________________________ X __________________________________
Debit Card Signature
Cash Back Platinum Debit Card Others ________________________
*Preferred and Priority Card can be applied by the customers who fall under this segment only.
**SME World Debit Card will be issued only to SME non individual customers. If you Name : _____________________________ X __________________________________
have selected this option please provide the mandatory details below: Signature
**Preferred Daily Card limit in INR for SME Debit Card (Please select one)
10,000 50,000 1 Lac 2 Lacs 3 Lac 5 Lacs Name : _____________________________ X __________________________________
__ Applicable for SME World Debit Card only.
Signature
1. Earn reward points on your Debit card on purchases at
merchant outlets and transactions at Standard Chartered
Bank ATM’s.
2. Earn 50 reward points on the 1 st three Purchase
transactions done in 1 st three months of account
activation**.
3. Redeem your reward points against cash. One reward
point is equal to one rupee.
4 Loss card liability cover of 50,000.
5. The Debit card can be used internationally at ATM’s and
at merchant outlets for purchases.
6. Visit www.standardchartered.co.in to check offers on
Debit Cards.
** Reward Points are not applicable on Cash back Platinum
Debit Card.
Debit Card SME Banking
Holders Debit Card
Cities Phonebanking Holders
Helpline nos. Phonebanking
Helpline nos.
Ahmedabad,
Bangalore,
Chennai, 3940 4444 / 3940 1616 /
Delhi, Hyderabad, 6601 4444 6601 1616
Kolkata, Mumbai
and Pune
Allahabad,
Amritsar, Bhopal,
Bhubaneshwar,
Chandigarh,
Cochin, 3940 444 / 3940 161 /
Debit Card
Coimbatore,
Indore, Jaipur, 6601 4444 6601 1614 Application Form
Jalandhar, Kanpur,
Lucknow,
Ludhiana, Nagpur,
Patna, Rajkot,
Surat, Vadodara
Jalgaon,
Guwahati,
Cuttack, Mysore, 1800-425-0109*/
Thiruvananthpuram, 1800 345 1000*
Vishakhapatnam, 1800-3000-1616*
Proddatur,
Dehradun,
Mathura,
Saharanpur and
Siliguri
* Toll Free www.standardchartered.co.in
For Internal Use
Customer ID No. :
Application approved by : __________________________________
__________________________________
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