Online Application Form

Dear Customer, this is an Online Application Form for Surat Money Prepaid Card. Please fill this form and complete the application & generate a Reference Number.
This Reference Number can be quoted at any issuance counter of Surat Municipal Corporation Civic Center to obtain your Surat Money card

Product Name*

Product Name should not be blank

Salutation*

Mrs

Salutation should not be blank

First Name*

First Name should not be blank

Last Name*

Last Name should not be blank

Gender*

Gender should not be blank

Date of Birth*

Date should not be blank

Current Address Line1

Current Address1 should not be blank

Current Address Line2

Current Address2 should not be blank

Current PinCode*

Current PinCode should not be blank

Current Country*

Current Country should not be blank

Current State*

Current State should not be blank

Current City*

Current City should not be blank

Mobile Number*

Email Id

Email Id should not be blank

CKYC Id

KYC Details

Disclaimer : As per new RBI guildelines, please complete your basic KYC. No document uploads required.
Any one of the following KYC Detail is mandatory.

Passport Number

NREGA Job Card

Voter Id

License Number

Aadhar Number

**Enter only last 4 digit of aadhar number

Verify Enter the otp

I have been provided various options by the Bank for establishing my identity/address proof for the purpose of issuance of Smart City cards and have voluntarily submitted my Aadhaar number to the Bank and hereby give my consent to the Bank to share my Aadhaar details with UIDAI, NPCI, concerned regulatory or statutory authorities as may be required under applicable laws. I have also been explained and informed in the local language understood by me about the consent and purpose of collecting the Aadhaar.

I hereby declare that I authorize ICICI Bank to download/fetch my CKYCRR record for the purpose of processing of Smart city product application and/or updating the CKYCRR record reference number in Bank’s records or any other related purposes.

I accept all declarations pertaining to ICICI Bank Surat Money Prepaid Card Application.(Please click here to view all declarations)

I do / do not have objections to ICICI bank Ltd., its group of companies, agents/ representatives to provide me/us information on various products, offers and services provided by ICICI Bank Ltd./ its group of companies through any mode (including without limitation through telephonic calls / SMSs / Emails) and authorize ICICI Bank Ltd., its group of companies, agents/representatives for the above purpose.

[ Refresh Image ]

DECLARATION

I have understood and hereby agree to the Terms and Conditions as applicable to my Surat Smart City Prepaid Card (“Card"). I understand that access to any changes / update in Terms and Conditions applicable to this relationship would be available on the website only. I do hereby declare that the information furnished in this form is true to the best of my knowledge and belief.

I declare, confirm, and agree:

1. To show my original Identity proof document for verification of my identity and information given by me in e-form during collection of the card

2. That all the particulars and information given in this Application Form (and all documents referred to or provided therewith) are true, correct, complete and up-to-date in all respects and I have not withheld any information. I understand that certain particulars given by me are required by the operational guidelines governing banking companies. I agree and undertake to provide any further information.

3. That I have read the Application Form and brochures and I am aware of all the terms/ conditions related to this card.

4. I agree and understand that ICICI Bank Limited / Group Companies reserve(s) the right to reject any Application Form without providing any reasons. I agree and understand that ICICI Bank Ltd. / its Group Companies reserve(s) the right to retain the Application Forms, and the documents provided therewith, including photographs and will not return the same to me.

5. I have also read and understood Terms and Conditions under which the Card is offered to me.

6. I authorise ICICI Bank and/ or its associates to verify, make enquiries with respect to any information or otherwise at residence or to contact me or any other source to obtain or provide any information that ICICI Bank may consider necessary in respect of or in relation to the information in this Application Form / further Application Forms including but not limited to confirming membership requirements or maintaining my account in good standing.

7. I hereby authorise ICICI Bank Ltd./ its Group Companies to exchange/ share or part with all the information/ data or documents relating to my Application to other ICICI Group Companies/ Banks/ Financial Institutions/ Credit Bureaus/ Agencies/ Statutory Bodies, such other persons as ICICI Bank Ltd./ its Group Companies may deem necessary or appropriated as may be required for use or processing of the said information by such person or furnishing of the processed information/ data/ products thereof to other Banks/ Financial Institutions liable for use of this information/ credit provider/ users registered with such persons provided such information/ data or documents shall be used and/or processed only for the purpose of this Card and I shall not hold ICICI Bank Ltd./ its Group Companies/ Bank/ Financial Institution liable.

8. I hereby authorise ICICI Bank Ltd/ its Group Companies to exchange/share or part with all the information/ data or documents relating to my Application to any such agencies, sub-contractors or such other persons as ICICI Bank Ltd./ its Group Companies may deem necessary or appropriated as may be required for use or processing of the said information/data by such person and shall not hold ICICI Bank Ltd./ its Group Companies or such person to whom information is shared liable for use of this information.

9. I authorise ICICI Bank Ltd. to issue the Card to me. I acknowledge that the issue and usage of the Card are governed by the Terms and Conditions as in force from time to time and agree to be bound by the same. I accept that the Terms and Conditions of the Card are liable to be amended by ICICI Bank Ltd. from time to time.

10. I shall, at all times comply with applicable laws and regulations while using this Card.

11. I understand that it shall be my responsibility to keep the Card, its PIN and password(s) protected and concealed at all times. I shall not hold ICICI Bank liable for any loss / damage/ harm resulting from a failure to do so.

12. I hereby agree to keep ICICI Bank fully indemnified against any loss / damage / harm that may be caused to ICICI Bank as a result of breach of any declarations, breach of any terms and conditions or any unauthorised / unlawful use of the Card.

13. I confirm that I have provided all the required information for the issuance of SitiLink pass to me, if applicable.

14. I understand that this is a minimum KYC card and I would be required to update full KYC within one year or as per prevailing regulatory guidelines.

By completing the online application form I accept all declarations mentioned above pertaining to the Surat Money Prepaid Card Application.