Branch: _______________ Date: ___/___/_____

Baroda Gift Card Customer Service Application

APPLICANTS’ INFORMATION

Customer Type: Existing Account Holder c 14 digit Account Number ____________________Non Existing Customer c

Title Mr./Mrs./Ms./_________Purchaser Name: _________________________________________________________

Mobile __________________Gender________ E Mail ID ____________________________ D.O.B DD / MM / YYYY

Address_________________________________________________________________________________________

_____________________ City ________________________State _____________________PIN __________________

KYC Document Detail (Not applicable for Bank of Baroda Account Holders)

Identity Proof Document Number Document issued by

I/We hereby agree to submit a copy of KYC documents to the bank and present original documents for verication towards Change Request of gift cards.

Signature of Purchaser:___________________________________________

CARD DETAILS

Kit No _____________ Last 4 Digits ____________ Available Balance ______________

Purchase Date or Month & Year___________ Purchaser Name _____________________________________________

Purchaser Mobile________________Beneciary Name______________________ Beneciary Mobile_______________

Please Tick whichever is applicable þ

Card Blocking: Reason for Blocking: Card Lost Damaged Fraud c c c

Type of Blocking: Temporary Blocking Permanent Blocking c c

Card Un-Blocking: Reason for Un-Blocking: Card Found Card Working c c

Update Communication details: New Mobile Number: _________________________

New E Mail ID: __________________________________

Statement Request: Start date: End date: DD_/__MM__/__YYYY_ DD_/__MM__/__YYYY_

New PIN Request: New pin will be delivered to branch after 7 working days & afterwards the same to be collected by c customer.

DECLARATION

I/We hereby agree to abide by the terms, conditions, rules, regulations and other statutory requirements applicable to respective prepaid card. I/We hereby declare that particulars given herein are true, correct and complete to the best of my knowledge and belief; the documents submitted along with this form are genuine. I/We also acknowledge that as part of purchasing this card, I/We will abide terms and conditions of the Gift card made available on the Bank Of Baroda website. I/We will be visiting Bank's website www.bankofbaroda.com for accessing transaction and balance information.

Purchaser Signature(s) __________________________

ACKNOWLEDGEMENT

Received authority to Modify Gift card with KIT No ____________vide Application serial No.______________ dated _____________

Signature of Branch ofcial: __________________

Baroda Gift Card ApplicationBranch: _______________ Date: ___/___/_____

APPLICANTS’ INFORMATION

Customer Type: Existing Account Holder c 14 digit Account Number ____________________Non Existing Customer c

Title Mr./Mrs./Ms./_________Purchaser Name: ______________________________________________________

Mobile __________________Gender________ E Mail ID _________________________ D.O.B DD / MM / YYYY

Address_________________________________________________________________________________________

_____________________ City ________________________State _____________________PIN __________________

PAYMENT DETAILS for ExistingAccount Holder

Account Number: _____________________________Customer ID ___________________

Type of Account SB / CA / OD / CC. Type of Entity: Retail Corporatec c

I hereby authorize you to debit my account toward the amount to be loaded on the cards and also the applicable card fee with applicable taxes

Signature of Purchaser (account holder(s)):____________________________________________

PAYMENT DETAILS for Non-Existing Customer

Amount of Remittance to Prepaid Account Rs. _______________ Date of Transaction ___/____/______

Mode of Transfer NEFT UPI IMPS RTGS Cheque Transaction ID__________________ c c c c c

Remitting Bank ___________Account Number_______________________ IFSC Code ___________ Branch _________

KYC Document Detail of Purchaser (Not applicable for Bank of Baroda Account Holders)

Identity Proof Document Number Document issued by

I/We hereby agree to submit a copy of KYC documents to the bank and present original documents for verication towards purchase of gift cards.

Signature of Purchaser (s)):_____________________________________________________________________

LOAD DETAILS

No of cards _______

Sl. No. Beneciary Name Load Amount Mobile no Email ID Address

DECLARATION

I/We hereby agree to abide by the terms, conditions, rules, regulations and other statutory requirements applicable to respective prepaid card. I/We hereby declare that particulars given herein are true, correct and complete to the best of my knowledge and belief; the documents submitted along with this form are genuine. I/We also acknowledge that as part of purchasing this card, I/We will abide terms and conditions of the Gift card made available on the Bank Of Baroda website. I/We will be visiting Bank's website www.bankofbaroda.com for accessing transaction and balance information.

Customer Signature(s) ____________________________

FOR BRANCH USE

Kit No: _____________Last 4 digits of Card: ________.

Card shall be activated within 24 hours from the time of Purchase/Replacement/Revalidation.Signature of the applicant veried.

Entered by: ___________________________Authorized by_______________________________________

BULK OR CORPORATE GIFT CARD PURCHASE ANNEXURE

CORPORATE INFORMATION

Customer Type: Existing Account Holder c Non Existing Customer c 14 digit Account Number ___________________

Authorized Signatory Name: _________________________________________Mobile___________________________

E Mail ID ______________________________ D.O.I____/____/______/ Address_______________________________

_______________________________________________________________________________________________

DECLARATION

The company conrms that the gift card so purchased shall be used by the company/organization/individual to distribute to its bonade employees/ agents/ distributors/ others (individuals only) and the company conrms that

• List of such persons to whom it is proposed to be distributed is enclosed or shall be furnished to the bank on demand within 8 days.

• These cards shall not be used for resale and/or misused.

• To abide by the terms, conditions, rules, regulations and other statutory requirements applicable to Gift cards, published by Bank of Baroda/ other competent/statutory authorities.

Name and Signature of Authorized Signature(s) __________________________

ACKNOWLEDGEMENT

Received authority to debit BOB Account No._______________ or amount received in prepaid collection Account for

against issuance of Baroda Gift Cards vide Application serial No.___________ dated _____________

Signature of Branch ofcial: __________________(All charges are exclusive of GST)

Load Amount Up to `2000 `50/-

Load Amount ̀ 2001 to ̀ 10,000 `100/-

Revalidation/ Replacement fee `100/- ( will be deducted from card available balance)

Pin Regeneration `100/- ( will be deducted from card available balance)

OLD CARD DETAILS (ONLY FOR REPLACEMENT/REVALIDATION)

Kit No _____________ Card Number ____________ Available Balance ______________

Purchase Date or Month & Year___________ Purchaser Name _______________________Purchaser Mobile________

Reason for Replacement: Card Lost Damaged Fraud c c c

Reason for Revalidation:Card Expired c