Primary Holder
____________________________________
Name

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/- (Rs. 600/- for IOC premium) to be debited from my Citibank Suvidha Account for the Photo ATM/Debit Card requested by me.

ATM/Debit Card No.: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|    (16 digits)
Signature : _________________________       Date: |__|__|  |__|__|  |__|__|__|__|     (dd / mm / yyyy)

Joint Account Holder
____________________________________
Name

I confirm that the attached photograph is the present true identity of myself, which I authorize Citibank, N.A., to apply to my Super ATM/Debit Card (IOC/Grocery/MTV/Shoppers stop) 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/- (Rs. 600/- for IOC premium) to be debited from my Citibank Suvidha Account for the Photo Super ATM/Debit Card (IOC/Grocery/MTV/Shoppers stop) requested by me.

ATM/Debit Card No.: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|    (16 digits)
Signature : _______________________       Date: |__|__|  |__|__|  |__|__|__|__|     (dd / mm / yyyy)
Citibank Suvidha A/c No.: |__|__|__|__|__|__|__|__|__|__|    (10 digits)
Rush this form to :

Citibank Suvidha
Anna Salai P.O.,
Chennai -600002