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I want the Kotak Urbane Gold Card I want the Kotak Velocity Platinum Card

I want the Kotak Trump Gold Card

Goodie type - Goodie name -

Advance Gift: -

About Me Form No. :IOOC873835

1. First Name SATISH
2. Middle Name KUMAR
3. Last Name ROBBI
4. Name as desired on the Card
(Maximum 19 characters)
5. Date of Birth 20-04-1986
6. Marital Status Married Single

6. Mother's Maiden Name

7. Gender Male Female

8. No. of Dependents
10. Educational Qualification
Secondary School High School Graduate

Post Graduate Others (pls. specify)

11. Net Monthly Salary Less than 25,000

12. PAN No.(Mandatory) AMNPR7957A
13. Type of Vehicle Four Wheeler Two Wheeler

Both none

14. Occupation Salaried Self Employed Business

Self Employed Professional

15. Email ID satishkumar.robbi@gmail.com

16. Mobile No. +91-9059024398
(To receive information on Email & SMS,Please give us your Email ID & Mobile No.)

17. If Salaried 18. If Self Employed

17A. Total Work Experience

17B. Desgination

Page No: 1
My Contact Details

19. Present Residence Address

Residence Status Owned by Owned by Rented with Friends
Self Parents
Rented with
Address MODI BUILDERS, B-202,
City Hyderabad Pincode 500055
Tel NO. STD Code Tel No.

20. Permanent Residence Address

Same as above (if different please fill below)

Address MODI BUILDERS, B-202,

City Hyderabad Pincode 500055
Tel NO. STD Code Tel No.

21. Office Address

Department Manufacturing

City Pincode
Tel No.(Office) STD Code Tel No.

22. Preferred Mailing Address Residence Office

Page No: 2
My Bank Detail

Loyalty Program
Program Name
Member Id.
Main Bank Details
Name of Bank
Account Number
Account Type Savings Current Other (Please Specify)

Customer Relationship Number

(In case you have a kotak account)
Main Credit Card Details
Name Of Bank
Card No.
Member Since Credit Limit

Sign up & Declaration

"I hereby declare that the particulars contained herein above are complete, true and correct to the best of my knowledge and
Kotak Mahindra Bank Ltd. ("Bank") is entitled to verify the same directly or through any third-party agency. I authorise the
Bank and its affiliates to use information from this application for marketing and administrative purposes. I confirm that I am a
resident of India. I further understand that the Bank may at its sole discretion accept or reject this application. I further agree to
be fully liable and authorise the Bank to debit the Kotak Credit Card account for all spends, fees and other charges, interest etc
on the Card. Service tax and surcharge at applicable rates will be charged on all fees, charges, interest etc. and I agree to pay the
same. In case I have applied for an Add-On card, I will be billed separately for the Add-On Card in the monthly statement. I will
be liable for all charges incurred on the Add-On Card. I undertake to notify the Bank immediately of any change in the above
details and information given by me. I hereby declare that I have read the Cardholder Agreement and I understand that upon my
request, print copy of the same would be couriered to me by the Bank. I further agree and understand that all documents given to
the Bank in connection with this application including, but not limited to photocopies of original documents, signature
verification, address verification and bank details shall become property of the Bank and shall not be returned to me. I hereby
confirm that I have read and understood the terms and conditions governing the entire business relationship with the Bank and
relating to the various services including but not limited to Cardholder Agreement, ATMs, Phone Banking, Home Banking, Net
Banking and Bill Payment. I understand that the Bank may at its sole discretion , discontinue or modify any of these services
completely or partially without any prior notice to me. I authorise the Bank, its group companies and their agencies to exchange
or share all information relating to me and my repayment history with Banks, financial institutions, credit bureaus, agencies,
statutory bodies etc. as may be required or as they deem fit. I expressly consent to Bank, its group companies, agents /
representatives to provide me information on various products, offers and services provided by the Bank / its group companies
through any mode ("including without limitation through telephone calls / SMS/ emails")."

Applicant Signature

Page No: 3
I want an Add-On Card

Name as desired on the Card

(Maximum 19 characters)
Date of Birth Gender Male Female

Relation with primary Spouse Parent

Card Holder Brother/Sister(above 18 years of age) Child(above 18 years of age)

I would limit on Add-On the card to Rs. 10,000 Rs. 20,000 Same as my primary card

Contact Details of Add-On Card Holder

Residence No. STD Code Tel No.
E-mail Id
I accept that the use of the Add-On card is goverened by the
acceptance of the card member agreement.I accept to pay a fee
of Rs, 199 for the add-on card.
Applicant Signature

For Bank Use

Date :Wed May 11 11:16:34 IST 2011 Client IP :

Promo Code Fee Code Card Sales Executive

Channel Code INPR Source Code INPR Other Card Sales
CSM code WB19 Cross Sell Telecaller
Referrer's Employee Code
Employee Group Code Cross-Sell Reference
Employee Code

Balance Transfer

I would like to opt for Balance Transfer facility. Upon approval from Kotak Mahindra Bank Credit Card, please transfer my
outstanding balance from
Name as it appears on my other Bank Credit Card
Other Bank Credit Card No.
Name of the Bank
Amount to be Transferred
Card Expiry Date
1.Amount transferred will be subject to a minimum of Rs.
2500/- & a max of 75% of the credit limit available on your
Kotak Card.(As on date of acceptance of your application for
*Subject to change from time to time. Applicant Signature