Application Form for Credit Card

If you wish to apply for a credit card, you have to use this application form. Complete all the required information in the form before sending it to be able to have a credit card issued to you.

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Application Form for 	Credit  Card 	
Instructions: 
1. 	Please  fill 	in 	all 	columns 	with required 	details 	in 	BLOCK 	LETTERS. 
2.  Absence 	
of 	mandatory  information 	may 	result 	in rejection 	of 	application.  Tick 	D 	boxes 
where  appropriate  and write  N.A. 	
if 	not 	applicable. 	Paste  recent 	colour 	
3. 	Submit  all 	documents  as requested 	at 	the 	end 	of 	the 	application 	form. 
passport size 
4.  Most 	
Important 	Terms  & Conditions 	(MITC) 	is 	available 	at 	LIC 	CSL 	office 	and 	published 	in 
Photograph. 	
our 	website http://www.liccards.com 
Do not 	
staple 
Please 	
sign  here  in 	Black 	Ink 	..,. 	
' 	
Personal  Information 	(Fields marked 	with* 	are mandatory) 	
1. 	*Name: 	Mr./Mrs	./	Ms. 	I 	I I I I I  I I  I I  I I I  I I  I I I  I I I  I I  I I I  I I I  I I I  I I  I I I  I 	I 	
First  Name  Middle Name  La
st  Nam e 	
2. 	* 	Name  to 	be 	embossed  on the  Card: 
(Max. 	19 	Characters) 	I 	I 	I 	I 	I 	I I 	I 	I 	I I 	I 	I 	I  I 	I 	I 	I 	I 	I 	
3. 	Date 	of 	Birth  : 	I 	I 	I I 	I 	I 	I  I 	I 	4. 	Sex 	: Male 	0 	FemaleD 	5. 	Nationality 	I 	I 	I 	I I 	I 	I 	I 	I 	
6. 	*Legal  Status 	: Resident 	0 	NRI 	0 	PIO 	D 	7. 	Marital 	St	a tus 	: 	Single 	0 	Married 	0 	No. 	of 	Dependants 	0 	
8. 	*PAN  No.: 	I 	I 	I I 	I I 	I 	I I 	I  I 	9. 	Passport 
No.: 	I 	I 	I 	I 	I 	I I 	I 	I 	I 	I 	Place 	of 	Issue  I 
I 	I I 	I 	I I 	I  I 	I 	I 	
10. 	*Voter 's 	ID: 	I 	I 	I  I 	I  I 	I I 	I  I 	111. 	Driving  License 	No.I 
I 	I I 	I 	I 	I 	I I 	I 	I Place 	of 	Issue  I 
I I 	I 	I I 	I I 	I  I 	I 	
12. 	*Vehicle 	: 	2 	wheeler 	0 	4 	wheeler  D None  D Vehicle  Make 	& 	Modell 	I I I I 	I I I 	I  I  I 	
13. 	*Mother' s Maiden  Name 	:I 	I I  I I  I I I  I I I 	I 	I  I 	I 	I I 	I 	I 	I 	I I 	I 	I I 	
14. 	*Name 	of 	Nominee  (for insurance  facility) 	I 	I 	I 	I 	I I 	I 	I 	I I 	I 	I 	I 	I 	I 	I 	I I 	I 	I 	I  I 	I 	I 	I 	
* 	Relationship  with 	Applicant 	I 
I 	I 	I I 	I 	I 	I  I 	I 	I 	I I 	I 	I 	I  I 	I 	I 	I I 	I 	I 	I 	I 	
Employment  Details 	(All fields  are mandatory) 	
15. 	Occupation: 	Salaried 	D 	Self 	Employed  D Professional  D Retired 	0 	Housewife 	0 	Others  D 	
16. 	If 	Salaried, 	employed  with: 	Govt. 	D 	PSU 	D 	MNC 	0 	Private 	0 	Partnership  D Others  D 	
17. 	Designation:  ......................................  Employed since: ..................................  yrs. Confirmed  in service:  Yes 	0 	NoD 	
18. 	If 	Self 	employed, 	field 	of 	activities: 	CA 	0 	Doctor 	0 	Lawyer 	0 	Consultant 	0 	Engineer  D Others  D 	
19. 	a) 	If 	LIC 	staff, 	S.R. 	No.I 	I 	I 	I 	I 	I 	I Date 	of 	joining ..........................  Dept./Branch ....................  Designation ............................  .. 	
b) 	If 	LIC 	Agent, Agency  Code 	No.I 	I I I I  I I I 	I  I 	I 	
Address 	(All  fields  are mandatory) 	
20. 	Present  Residential  Address 	
Cit	y 	
State 	PIN 	
Tel. 	No. 	*Mobile 	No	. 	
*EmaiiiD