Personal Details :

Mr. /Mrs./ Ms.

(Surname) (First Name) (Middle Name)

D D M M Y Y Y YDate :

For Resident / Non Resident Individuals

E-mail : ibhelp@cosmosbank.in Website : www.cosmosbank.com

Branch : ________________________

(Please fill the form in BLOCK Letters only)

(Please leave one block space between two words)

CUST ID

Communication Address :

Details of accounts for which Internet Banking services are to be activated.

INTERNET BANKING APPLICATION FORM

Order

PrimaryAccount

1st Account

2nd Account

3rd Account

4th Account

Bank Account Number A/C Operation Customer ID*

(*If you are not aware of your Customer ID, please enquire at your nearest branch)

Access

View Only

Transaction

View Only

Transaction

View Only

Transaction

View Only

Transaction

View Only

Transaction

Sr. No. :

ESTD. 1906 (Multistate Scheduled Bank)THE COSMOS CO-OP. BANK LTD.

(with STD Code) (with STD Code)

Flat/Door No./ Building Name :

Survey No. / Road Name :

Nearest Landmark :

City:

Phone (R) Phone (O) Mobile

Email ID :

Residential Status : Resident Indian Non Resident Indian Foreign National

Date of Birth :

(Please provide complete address for faster courier delivery)

Pin Code: Country

State

Area / Locality Name :

D D M M Y Y Y Y Mother's Name :

D D M M Y Y Y YDate :

Comprehensive DeclarationI have read, understood and agreed to all terms & conditions including the interpretation of rules, risk, limits, charges & other conditions. Those will be applicable as updated from time to time under the heading “Terms and Conditions” for Internet Banking on Bank’s website www.cosmosbank.com

Further in case if you find multiple customer Ids attached for my different accounts, I accept & agree to merge those multiple Customer Ids in one Customer ID, which will be used as authenticated login user ID for Internet Banking.

Instructionsl In case of Joint accounts, the applicant is required to submit the attached mandate for the joint account holder(s).l Account holders can avail Internet Banking facility only where the mode of operation of bank account is Single / Either or Survivor /

Anyone or Survivor / Joint.l Cosmos Bank shall not be responsible and liable to monitor the nature of expense incurred by the use of the said Net Banking facility.

Joint Holder MandateApplication for individuals having Joint account operations.

1) Name : _______________________________________

User ID : ______________________________________

Level : ______________________________________

E-mail : _______________________________________

Mobile No. ______________________________________

Birth Date : ____________ Mother's Name _____________

Signature _______________________________________

are the joint account holders of Account number I/We hereby authorize the other joint holders to have View / Transaction access for the said account on my/our behalf.

lI/We further agree that since the mode of operation of our Account is joint (one initiator & all other approvers), the transaction/s initiated by any one holder will have to be approved by other joint holder/s. I/We further affirm, confirm and undertake that I/We will be responsible for any action by any of us using Internet Banking facility

lI/We hereby state that should I/we wish to change/revoke the above authorization, I/We shall duly submit a change mandate to that effect to the bank. I/We hereby agree that till 10 (Ten) working days, after receipt of such change mandate existing account operations shall be hold good.

lI/We confirm having read and understood the terms & conditions for the usage of Internet Banking service as displayed on the bank’s website www.cosmosbank.com I/We accept and agree to be bound by the said terms and conditions.

To be signed by all account holders

Account Operation : Either or Survivor (EOS) Joint / Both Any One Any Two

Important Note : l Level - 1 Initiater l Level - 2, 3 Approver l Level - 4 Initiater & Approver (Only in case of A/c operation E/S)

1. Name __________________________________________

Signature ____________________

3. Name __________________________________________

Signature ____________________

2. Name __________________________________________

Signature ____________________

4. Name __________________________________________

Signature ____________________

CUST ID

I/We

1.

2.

3.

4.

Former or Survivor (F/S) Any Three Others

2) Name : _______________________________________

User ID : ______________________________________

Level : ______________________________________

E-mail : _______________________________________

Mobile No. ______________________________________

Birth Date : ____________ Mother's Name _____________

Signature _______________________________________

3) Name : _______________________________________

User ID : ______________________________________

Level : ______________________________________

E-mail : _______________________________________

Mobile No. ______________________________________

Birth Date : ____________ Mother's Name _____________

Signature _______________________________________

4) Name : _______________________________________

User ID : ______________________________________

Level : ______________________________________

E-mail : _______________________________________

Mobile No. ______________________________________

Birth Date : ____________ Mother's Name _____________

Signature _______________________________________

For Office Use Only (To be filled by Branch Officer)

Signature of the Officer :

Name : ________________________________________

At the time of accepting the application :

All A/C Nos, A/C Holders and mode of operation on

All signatures and other details on

Documents available on Record-

1) Photo Identity : 2) Photo :

3) Address Proof : 4) PAN No. / Form 60 :

Application Accepted By : Verified By :-

Name : _____________________________________

Designation : ________________________________

Employee ID : ________________________________

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

D D M M Y Y Y Y

D D M M Y Y Y Y

Designation : ______________________________

Employee ID : _____________________________

Signature of the verifying Officer :

Customer ID Merging & Verified : Customer is KYC complied :

Unwanted Customer ID Disabled : Customer ID merging NA (Not Applicable) :

Unique Customer ID after merging all duplicate customer records is :

Checked & Verified accounts are not : Frozen Closed Inactive

Minor Overdue

NRE / NRO status verified :

Valid Passport available on record Valid Visa available on record

CUST ID

Email ID updated in Finacle : Mobile No. updated in Finacle :

Confirmed :

Application Accepted in Internet Banking Cell :-

Cust ID :

Name of the Officer : _________________________

Employee ID : _____________

For Office Use Only (To be filled by Internet banking Cell)

Signature : __________________

D D M M Y Y Y YDate :

Checked Details & found correct in Finacle :

Account Created :

Signature : __________________

Name of the Officer : _________________________

Signature : __________________

Name of the Officer : _________________________

Account Verified :

If Application is rejected, then specify the reason.

Employee ID : _____________

Employee ID : _____________

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