Common-Application-Form
(For electronically Sourced Accounts)
Application ID* -…………………………
I hereby provide my consent to ICICI Bank to process my application for the below selected credit card:
T i ck Annual Fee (2nd year Supplem entary
Credit Card Ca rd Type Joining Fee
(√) Onw ards) *# Card (if availed)
ICICI Bank Coral Credit Card Visa Rs. 500 + GST Rs. 500 + GST NIL
ICICI Bank Platinum Chip Credit Card Visa NIL NIL NIL
ICICI Bank HPCL Coral Credit Card Visa Rs. 199 + GST Rs. 199 + GST NIL
Accelero ICICI Bank Credit Card Visa Rs.499 + GST Rs.499 + GST Nil
Manchester United Platinum Credit One Time Fee of Rs.
Visa Rs. 499 + GST Rs. 499 + GST
Card 100 + GST
Manchester United Signature Credit One Time Fee of Rs.
Visa Rs. 2,499 + GST Rs. 2,499 + GST
Card 100 + GST
MakeMyTrip ICICI One Time Fee of Rs.
Visa Rs. 2,500 + GST NIL
Bank Signature Credit Card 250 + GST
MakeMyTrip ICICI One Time Fee of Rs.
Visa Rs. 500 + GST NIL
Bank Platinum Credit Card 250 + GST
NIL (Starter free
plan), Rs. 49 + GST
Mine Credit Card by ICICI Bank Visa NIL (Pro 49 plan), Rs. 149 NIL
+ GST (Premium 149
plan)
ICICI Bank HPCL One Time Fee of Rs.
Visa Rs. 500 +GST Rs. 500 + GST
Super Saver Credit Card 100 + GST
InterMiles ICICI Bank Sapphiro
Visa Rs. 5,000 + GST Rs. 5,000 + GST Rs. 250 + GST
Credit Card
InterMiles ICICI Bank Rubyx Credit
Visa Rs. 2,500 + GST Rs. 2,500 + GST Rs. 250 + GST
Card
InterMiles ICICI Bank Coral Credit
Visa Rs. 1,250 + GST Rs. 1,250 + GST Rs. 250 + GST
Card
*Subject to Minimum spend; Minimum spend criteria varies with the card variant. ; #GST is applicable on Joining and Annual Fe e
I am submitting the Income Proof documents as mentioned below for further processing of this application.
Income Proof 1 Income Proof 2
Document Name Reference No. Document Name Reference No.
I am submitting the KYC documents (to ICICI Bank Staff) as mentioned below for further processing of this application.
Identity/Address Proof 1 Identity/Address Proof 2
Document Name Reference No. Document Name Reference No.
I the undersigned declare, confirm and agree:
i. I have authorized, the representative of ICICI Bank Limited having to enter the account opening details on my behalf and as
per the instructions given by me in the electronic application form.
ii. That I have reviewed and verified the details entered by him/her in the electronic application form and declare the same to
be true, correct and updated and the application number mentioned above with respect to the electronic application form
has been generated by ICICI Bank post my review, verification and confirmation of the application details.
iii. I understand the electronic application form and physical confirmation form together shall constitute credit card application
form for the application number mentioned above
iv. That I have read, understood and hereby agree to Terms and Conditions and MITC (Most Important Terms and Conditions)
applicable to my credit card application set forth on the website www.icicibank.com. I understand that access to any
changes/updation in Terms and Conditions applicable to this application would be available on the website only.
v. I authorize ICICI Bank to exchange, share or part with all the information relating to me and repayment history to credit
bureaus, agencies, statutory bodies, market research agencies for conducting research as may be required and shall not
hold ICICI Bank (or market research agencies) liable for use/sharing of this information; and share Card application details
and status, Card account status, reward details and Card activity data with its affiliates for it to update its records to provide
services & benefits with respect to the Card.
vi. I have no objection to ICICI Bank Limited, its group companies, agents/representatives to provide me information on various
products, offers and services provided by ICICI Bank Limited/its group companies through any mode (including without
limitation through telephone calls/SMSs/e-mails) and authorize ICICI Bank Limited, its group companies,
agents/representatives for the above purpose. ([ ] Yes / [ ] No)
vii. I have no objection to ICICI Bank sharing my information with any parent, subsidiary, affiliates or associate of ICICI Bank, for
the purposes of marketing and offering various products and services of ICICI Bank or its group companies, subsidiaries,
affiliates and/or associates ([ ] Yes / [ ] No)
viii. Manchester United I hereby consent to ICICI Bank Ltd. sharing my Name, Contact Details, Address, Year of Birth, Date of
First Purchase and Date of Last Purchase with Manchester United Football Club Limited and their affiliates for the purpose
of marketing, curated offers etc. ([ ] Yes / [ ] No)
ix. Manchester United want you to be first to know about New Signings, Competitions, Clubs News, Tickets,
Availability, and occasional offers from official sponsors and partners. ([ ] Yes / [ ] No)
x. For MakeMyTrip ICICI Bank Credit Card: I hereby authorize ICICI Bank Ltd (“ICICI Bank”) to share my data or informatio n
associated with my MakeMyTrip ICICI Bank Credit Card ("Card application”) (i) registered E-mail ID; (ii) registered Mobile
number; (iii) Card variant availed of(Platinum/Signature); (iv) Credit Card account no. with MakeMyTrip (India) Private
Limited and its affiliates (“MMT”) to update its records and provide me services, rewards & benefits with respect to the Card.
xi. For MakeMyTrip ICICI Bank Credit Card: I hereby agree that in case the e-mail ID provided by me in the Card application
does not have a corresponding MMT account, MMT shall provide me wi th services, rewards & benefits associated with the
Card on my MMT account linked to my registered mobile number. In case my email ID or mobile number are not present
in any MMT account, MMT shall create a new MMT account on my behalf with my e-mail ID and/or mobile number, provided
under the Card application. MMT shall update me with details of the new MMT account and steps to access the new MMT
account by way of an SMS and/or email.
xii. InterMiles Membership: I/We authorize ICICI Bank to exchange, share or p art with all the information relating to me/us as
contained in this application form and/or the details of the InterMiles ICICI Bank Credit Card, if any to be issued to me with
the InterMiles Programme Partner and/or any other third party pursuant to ICICI Bank arrangement with
InterMiles/JetPrivilege and/or any other third party in relation to the InterMiles ICICI Bank Credit Card, as may be required
or as ICICI Bank may deem fit and I/We shall not hold ICICI Bank liable for use/sharing of this information. Note: If you are
not an InterMiles Member, you will be automatically enrolled. Also, if we do not receive your existing InterMiles membershi p
number in this application form, a new InterMiles membership number will be allotted to you and linked to your Credit Card.
Please note that by applying for the InterMiles ICICI Bank Credit Card you are consenting to the Terms and Conditions of
membership of the InterMiles programme. These can be found at www.intermiles.com
xiii. ICICI Bank Rewards powered by PAYBACK: You hereby authorize ICICI Bank Ltd ("ICICI Bank") to share your data or
information associated with your ICICI Bank Credit Card ("Card application") (i) Name (ii) E -Mail ID (ii) Mobile number (iii)
Date of Birth (iv) Address (vi) Credit Card Account number with Loyalty Solutions and Research Pvt. Ltd. and its affiliates
("LSRPL") to update in your PAYBACK account and provide services and benefits with respect to the PAYBACK reward
programme on your ICICI Bank Credit Card.
xiv. For more information regarding information disclosures, please check ICICI Bank Card Terms & Conditions.
Date: Place: Primary Card Applicant Sign
__________________________
INCOME DOCUMENTS CERTIFICATE (To be Filled by the Executive)
I have met Mr./Ms.__________________________, in person at his/her residence/office/branch and hereby confirm that the Income
documents collected from the applicant as produced by the applicant. I also confirm that the form has been signed by the
applicant in my presence.
i. Executive Name: iii. Executive Signature
ii. Executive Emp. Code:
KYC CERTIFICATE (To be Filled by the ICICI Bank Staff)
I have met Mr./Ms.__________________________, in person at his/her residence/office/branch and hereby confirm the identity
and address provided in the application matches against originals as produced by the applicant. The Income documents are
collected from the applicant as produced by the applicant. I also confirm that the form has been signed b y the applicant in my
presence.
i. ICICI Bank Emp. Name: iii. ICICI Bank Employee Signature
ii. ICICI Bank Emp. Code:
Documents Certified E-KYC data Data received from Digital KYC Equivalent
received copies received from offline verification process edocument
UIDAI
