Form A PDF

Customer Request Form : Form A (Includes Direct Banking Channel Request)
(Change/Update related to : Address, Contact details, Internet Banking, Debit Card issue/reissue, Alerts, Personal & Account Detail, Aadhaar Card No.
RBL Bank Limited

I/ We hereby request and authorize the Bank to initiate processing basis the provided instructions:-
(For Bank Use Only) Service Request No. Date D D M M Y Y Y Y
PLEASE USE BLOCK LETTERS AND ATTACH SELF-ATTESTED DOCUMENT PROOFS AS PER REQUIREMENT.
TICK & SIGN AS APPLICABLE AND STRIKE OUT THE IRRELEVANT PORTIONS.
Customer Name
Customer Id Account Number
ADDRESS (Self-Attested Proofs to be attached)
New Mailing Address Update* New Permanent Address Update
(*In case proof of ‘New Mailing Address’ is not available, please contact your home branch)
Address
Building / Street City
State Pin/Zip Code Country
Landmark*
(*Please mention prominent Landmark to ensure Delivery of Account Collaterals)
There is no change in Telephone / Mobile Number / Email Address (Please fill below Contact Details section in case of change)
For Branch Use Only
This Section is applicable for NRI Customers only. Please tick the applicable option and provide the details below.
Face to Face Non Face to Face (For non-face to face NRI customers two address proofs are mandatory)
CONTACT DETAILS
Change Addition
Telephone (Residence) : Signature of Applicant 1
ISD STD Code
Telephone (Office) : Extn. :

ISD STD Code
Mobile Number : Signature of Applicant 2

ISD STD Code
Email Address**:
**All accounts linked to Customer ID of the 1st Applicant will be registered for E-statements on the email id mentioned and physical statements will not be sent.
(Please fill Corporate Net Banking request form for change/update of Email id/mobile number for Corporate Net Banking)
DIRECT BANKING CHANNEL & ALERT REGISTRATION & RE-ISSUE

These facilities are provided only for the Accounts where mode of operations is singly or either or survivor.
Internet Banking (Providing email address is mandatory. For Corporate Net-Banking Request a separate form is to be filled)
Alerts Registration*** : SMS Email
You will be registered for alerts and the following SMS alerts : Credit/Debit transaction greater than ` 5000/- for Signature of Applicant 1
Current Account and ` 2000/- for savings Account. If you need to add/modify de-register for alerts please visit your
nearest branch. To know the applicable charges for your product, please visit your nearest branch or our website
www.rblbank.com. ***Mandatory/Regulatory alerts will be triggered to your registered email id and mobile number
even without registration.
I/ We hereby agree to take necessary precaution to ensure the security and access to my/our email account to Signature of Applicant 2
prevent unauthorized use.
DEBIT CARD
Please select one of the below options
New Card Issuance
Card Re-issue; Reason for re-issue : _______________________________________________________________________________________________
(Mandatory)
Card Upgrade
Please select your Debit Card
International Debit Card Domestic Debit Card Signature of Applicant 1
Ver : SCGS/Jan/2017
(Debit card cannot be issued if the Mode of operation of the account is Jointly. International debit cards are not issued for NRO Accounts)
For Savings Account For Current Account

Titanium First Platinum First Women’s First Business First India Startup Club
Signature of Applicant 2
Please note that in case your are mapped to a particular segment, debit card for the respective segment will be issued by default
ACKNOWLEDGEMENT Date D D M M Y Y Y Y
Customer ID/Account No. Service Request No.
Customer Name
Request related to : _______________________________________________________________________
____________________________________________________________________________________________ Branch Stamp & Signature of Official
Email us at : customercare@rblbank.com
Customer Service (24 X 7) : +91 22 61156300 to 99; Toll Free No.: 1800 123 8040 Website www.rblbank.com
SMS Banking : To know Debit Card : Best in class Mobile Banking : Visit Personal Internet Banking : Log in Personal Internet Banking using
more type HELP & send features & benefits. To apply https://m.rblbank.com/MobileBank/on Debit Card & PIN or visit nearest branch.
to 9223366333 visit nearest Branch your mobile browsers. The Corporate Internet Banking facility is also available.
PERSONAL & ACCOUNT DETAILS MAINTENANCE (Self-Attested Proofs to be attached)
PAN Date of Birth D D M M Y Y Y Y Aadhaar No.
Name
For Branch Use Only
This Section is applicable for NRI Customers only. Please tick the applicable option and provide the details above.
Face to Face Non Face to Face (Two ID proofs are mandatory for non-face customers )
SIGNATURE (Self-Attested Proofs to be attached)

Change in Signature / Signature Update
Existing Signature of Applicant New Signature of Applicant
TERMS & CONDITIONS FOR CHANGE REQUEST / DEBIT CARD:

I/ We hereby agree/s having read and understand the terms and conditions below for effecting such changes:
• The changes requested would be effected in records of RBL Bank Limited within reasonable
period after the receipt of necessary
supporting documents.
• All deliverables will be sent to the communication address as per the latest records available with RBL Bank.
• RBL Bank shall not be responsible for return/ dishonor of any outstanding/ unpaid cheque (s)/ debit request which are in transit/ to be actioned by RBL
Bank and not in accordance with the new signature (s)/ operating instructions.
• Applicable charges shall be debited from the account mentioned.
• In case, non-individual Cardholder wants to change their mode of operation to jointly then the Cardholder will have to give a separate request for Card
closure in addition to request for changes in the Account structure. In case, Cardholder who is authorized signatory of the Account and wants to quit,
then the Accountholder will have to give a separate request (Refer below*) for Card closure in addition to request for changes in the Account
structure.
*24 Hours Hotline – 1800 123 8040
Or, SMS - BLOCK <Space> Card No
CUSTOMER DECLARATION
• I/We understand and declare that all the particulars filled in the form are true, correct, complete & up-to-date in all respects and no information is
withheld.
• I/ We confirm to have read and understood the Terms & Conditions pertaining to the changes mentioned in this form.
• I/ We have read and understood and agree to abide and bound by all the provisions of the Terms and Conditions for Debit Card
published on the Banks’s website www.rblbank.com and given along with Debit Card.
Date D D MM Y Y Y Y Signature of Applicant 1 Signature of Applicant 2
(For Branch Use Only) Branch Branch Code
I hereby certify that the customer's signature has been verified from Bank's records and is found to be true as per the
operating mandate.
Verified By (Bank Official Name & Sign): __________________ Approved By (Bank Official Name & Sign): ____________________
(For Processing Unit Use Only)
Checked By (Bank Official Name & Sign): __________________ Verified By (Bank Official Name & Sign): ____________________
Terms & Conditions for change request:

I/ We hereby agree/s having read and understand the terms and conditions below for effecting such changes:
• The changes requested would be effected in records of RBL Bank Limited within reasonable period after the receipt of
necessary supporting documents.
• All deliverables will be sent to the communication address as per the latest records available with RBL Bank.
• RBL Bank shall not be responsible for return/ dishonor of any outstanding/ unpaid cheque (s)/ debit request which are in transit/ to be actioned by RBL
Bank and not in accordance with the new signature (s)/ operating instructions.
• Applicable charges shall be debited from the account mentioned.
List of Self-Attested Proofs required: Few accepted documents*
• Address Change: Valid Passport, Voter's ID card, Utility Bill (Electricity/Telephone /Mobile/Piped Gas/Broadband – not more than 3 months old)
Aadhaar Card.
• Signature: Pan Card, Passport, Drivers' License (Valid).
• Name Change: Pan Card, Valid Passport, Valid Drivers' License, Gazette Copy.
• * Additional documents may be demanded, if required. Please contact the branch for additional acceptable document.

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Customer Request Form : Form A (Includes Direct Banking Channel Request)

RBL Bank Limited

Telephone (Office) : Extn. :

Mobile Number : Signature of Applicant 2

DIRECT BANKING CHANNEL & ALERT REGISTRATION & RE-ISSUE

For Savings Account For Current Account

____________________________________________________________________________________________ Branch Stamp & Signature of Official

SIGNATURE (Self-Attested Proofs to be attached)

Existing Signature of Applicant New Signature of Applicant

TERMS & CONDITIONS FOR CHANGE REQUEST / DEBIT CARD:

Date D D MM Y Y Y Y Signature of Applicant 1 Signature of Applicant 2

(For Branch Use Only) Branch Branch Code

(For Processing Unit Use Only)

Terms & Conditions for change request:

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