To apply for a Citibank ATM/Debit Card, please tick your choice

Primary Applicant Joint Applicant(if any)

1. Do you need an ATM/ Debit Card? c Yes c No* c Yes c No*

*Without an ATM/ Debit Card you will not have access to ATM/ Internet/ Mobile banking facilities provided by the bank.

2. If you have selected “yes” above, do you need c Yes c No** c Yes c No**

international transactions enabled on your NRE ATM/ Debit Card?

**Without specific consent for international activation, you will not be able to use your ATM/ Debit card abroad in an ATM, point of sale or online

Should you wish to activate international transactions on your NRE debit card at a later date, please complete this form and submit the same to the nearest

NRI Center or a branch of Citibank India at that point of time.

For customers who do not want an ATM/Debit Card: I/We are aware that without an ATM/Debit card, I/we will not have access

to the ATM or Internet/ Mobile Banking facilities provided by the bank. I / We acknowledge that I/we do not wish to avail this

facility

I/ We understand the usage of my ATM/Debit Card is subject to availability of the requisite balance in my Savings/Current

Account(s) or any other specific criteria/ terms that may be imposed by Citibank in this regard from time to time.

This product/service is offered by branches of Citibank N.A. in India. © 2017 Citigroup Inc. Citi and Arc Design are registered service marks of Citigroup Inc. or its affiliates used and registered throughout the world.

PRIMARY APPLICANT’S SIGNATURE JOINT APPLICANT’S SIGNATURE (if any)

DEBIT CARD REQUEST APPLICATION FORM

VER 1.1/NR/NA/ALL/DCRF/WPC/02-17

D D M M Y Y Y YDate : D D M M Y Y Y YDate :

JP