Request form for availing Bank of Indla Staronnect (Core Banking) Services RETAIL

(Internet /SMS / WAP / Tele Banking) for Individual / Sole-Proprletorship concern Page 1 of 2

Requost R
The Manager Form No. Branch Code Serial Nurnber
Bank of India. A2 Branch. (To be filed by the branch)

Dear Sir / Madam, Account no 151220llacooo45

Request for availing BÌI StarConnect(Core Banking) Services- Internet/ SMS/ WAP/ Tele Banking

First Name Middl e Name Last Name

My Customer ID(s)
Residential Status:DIndian Resident ONon Resident Indian D
Foreigner
Name of the Firm*
Activity Type* JTrading I Manufacturing JNGO Services Others
(* Applicable in case of Sole-Proprietorship/ Partnership/ Body Corporate concern)
Date of Birth
(DD/ MM/ Y)
lo6/1444 Mother's Maiden Name

I wish to have any one of the following User ID mentioned in the order of preference.
Chanonahhaaa
Guidelines for User ID* selection:
1) The first character has to be an alphabet only 1.
|2) Minimum length is 6 and maxdmum length is 10
3) Cannot contain special characters like *@, &,+ 2, Koish qq30
4) Cannot contain spaces 3.
*User ID shall be allotted to you subject to its availability and shall be advised by a PIN Mailer at your communication address.

Services Required (please tickyour ch oicè

Internet Banking:
Fund Transfer Facility V Yes D No V WAP Banking D SMS Banking
Tele Banking With out Fund Transfer With Fund Transfer

Communication address
RAN kAREALuA GANGUT
Cty State NAKIARAS RA Pin Code 46031
Phone(0) Phone(R)
Mobile a|g3loSIA|? EFax Email
Decaration
Iconfirm that I have read and understood the *Terms and Conditions" annexed hereto / as glven on the Bank's web site for the usage of Bank of
Indla Starnnet (Core Ba nkind Services and unconditlonally accept and agree to ablde by the same and such
Bank of India (BoI) from dme to tme. I am aware of nature of sservlces offered by Bank of Indla through
other modiflcations made by
Services shall pay charges /axes as pplcabie,
and the na Star (Core Banking)
lcable, from time to time, as set forth In Bank of Indla's web slte or communlcated / demanded by
Bank of Indla from time to tme, I also agree to all theroterms /conditlons of opening /
for usage of Bank of Indla Star applying / malntalning / operating as appllcable / modlfied
(Core Banking Services - as may be In force from time to time. I further authorlze Bank of India to
debit my Account(s) towards charges for avalling of servces through Bank of Indla
Starannect (Core Banklng) Services. I declare that all the
particulars and Iinformatlon glven In this form are true, correct, complete and up-to-date
agree and undertake to provde any further Informatlon that Bank of Indla In all respects and I, have not withheld Informaton. I
right to reject any appllcatlon or bloc or withdraw the Bank of India may requlre. I agree and understand Sorvlices -
that
to
Bank of India reserves the
asslgning any reason. I authortze Bank of Indla or thelr Staronet (Corg any or all account(s) without
respect of or In relation to information In this agents to make references and enet BOI or ts agents consider
appllcatlon/further appllcations. necessary In
Date 22y02,024 Signature
Place kae Name

Bank ofIndia: Staone (Core Banking) Services - Request Form

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