= APPLICATION FORM Borderless tie Prepaid thomascookcin Serial No.: Please read the Important Information below: (Complete in BLOCK LETTERS) CEFOIREIGNIEXGHANGE & Title (Mr/Mrs/Ms/Miss): First Name(s): Last Name(s}: PAN number: Passport number: Date of Issue: Place of Issue: Residential Address: Postcode/Pin Code: Home Phone: Mobile Phone: Email: Date of Birth: Mother's Maiden Name: Father's Middle Name: Important Information ‘Thomas Cook Borderless Prepaid Card is issued by Thomas Cook (Indi) Ltd, Personal Information is collected by Thomas Cook (India) Ltd. or authorised Agents appointed by Thomas Cook (India) Ltd, for the purposes relating to providing the product andor service requested. By successfully applying for the Thomas Cook Borderless Prepaid Card, you are consenting to Thomas Cook (India) Ltd. using your Personal Information to notify you of our related products, promotions and customer surveys that we may conduct from time to time. If you have any privacy concerns, please contact us on cardservices@borderlessprepaid.com By ticking this box, ou consent to being contacted by emailor text message in relation to Thomas Cook Borderless Prepaid Card features and promations and our related products, promotions and customer surveys that we may conduct from time to time. For more information please se the ful Terms and Cottons Cardholder declaration: "Thereby apply forthe iseue of a Thomas Cook Borderlats Prepaid Card to me and declare thatthe information included in he application is true ‘and correct and that | am eligible to apply for the Card | accept that Thomas Cook (India) Ltd, or its Agents, are entitled in its absolute discretion to accept or reject this application without assigning any reason whatsoover. tis my responsibility to obtain the Terms and Conditions as ‘applicable to the Thomas Cook Borderless Prepaid Card and to read and understand the same. By accepting and using the Card, | agree to be bound by the Agreement detailed inthe Terms and Conditions brochure and the rules and regulations in force from time to time, a5 ised by RBI, FEMA 1999. By signing this application form, | willbe deemed to have accepted the Agreement. ‘have received a copy of the Table of Fees and Limits and the Terms and Conditions. Signature of Customer Date: ‘Additional Declaration for Parent / Legal Guardian where the cardholder is under 18 years old: | the undersigned, warrant and represent that | am the parent or legal guardian of the minor whose name appears asthe cardholder above and by signing below | confirm that | am entering into this Agreement as parent / legal guatdian on behalf of the cardholder who isa minor. ‘Signature of Parent / Legal Guardian Name of Parent / Legal Guardia Date‘Additional Declaration for Business Card Application: In the case of Thomas Cook Borderless Prepaid Cards being issued to me for travel at the request of my employer nnn senna | ereby authorise Thomas Cook (India) Ltd, or an authorised Agent appointed by Thomas Cook (india) Ltd, to load, reload, cash out unspent funds and cancel any Cards at the request of authorised persons acting on behalf of saic ‘employer. Signature of Customer Date: FOR OFFICE USE ONLY ‘To be completed while the customer is present. Please indicate if this is for: | Anew Card and/or Additional Card Card number: KX XXX XII Additional Card number (if purchased}: KIX KIKI IC ee Cone US Dollar GB Pound Euro Australian Dollar Canadian Dollar Swiss Francs Japanese Yen Singapore Dollar Valid documents collected and verified (in original) by Agent: | Passport || Visa | | Air Ticket |_| Form Az Branch/Agent Code: Branch/Agent Name: Issuing Authority Name: Signature of Issuing Authority: Date: Time: Place: MULTICURRENCY CARDS Erase Boundaries. Wavel Smooth.