F-5 ACCOUNT OPENING FORM

Applicant/s Signature/s Signature of verifying official

(For Bank’s use)
The Citizen Co-operative Bank Ltd. CIN : ____________ A/c. No. __________
Regd. Office: “Lakshdeep”, Near Damodar Temple, Memb. No. ___________
Vasco-da-Gama, Goa - 403 802
Tel.: 0832-2511033, Fax: 0832-2519290

Branch ___________________
Latest Photo
duly attested
Please open a Term Deposit Account as detailed below: by Bank
[Please ( ) where applicable]

TYPE OF ACCOUNT
INTRODUCTION

Reinvestment Deposit Rs. ______________ I/We confirm the identity, occupation and address of the applicants.
Fixed: Credit monthly/quarterly interest to my A/c. No. _________
Name
Automatic Renewal Term _________ R.O.I.__________
Account No. Signature
In case existing customer of The Citizen Co-op. Bank Ltd., please mention A/c. No. ___________________
___________________ Branch. NOMINATION FORM
(USE BLOCK LETTERS)
I/We _________________________________________________________________________________
FULL NAME (S) DATE OF BIRTH/ Name (s)
(Income Tax PAN) OCCUPATION ADDRESS WITH TELEPHONE NOS. Nominate the following person to whom in the event of my/our/minor’s death the amount of deposit in the
INCEPTION
account may be returned by The Citizen Co-op. Bank Ltd.
A. Name & Address Relationship with
Age
If Nominee is a minor
( ) Depositor, if any his/her date of birth

B.

C. * As the nominee is a minor on this date, I/We appoint _________________________________________

(Name, Address & Age)
In case applicant is a minor please specify: ___________________________________________________________________________________ to
Name of guardian ________________________________ Relationship ___________________________ receive the amount of the deposit in the account on behalf of the nominee in the event of my/our/minor’s death
during the minority of the nominee.
MODE OF OPERATION
________________________________ ______________________________
SINGLE JOINT EITHER OR SURVIVOR Name, Signature of Witness & Address + Signature (s) of depositor (s)
ANY ONE OR SURVIVOR FORMER/LATTER OR SURVIVOR
(Please specify) Place ___________________________
* Strike out if nominee is not a minor + Where deposit is made in the name of a
minor, nomination should be signed by a
TAX DEDUCTION AT SOURCE U/S 194A OF IT ACT 1961 person lawfully entitled to act on behalf of
________________________________ the minor.
DEDUCT TAX FROM INTEREST EARNED MEMBER OF THE BANK, TD.S. NOT APPLICABLE
FORM 15H/G ENCLOSED NO TDS APPLICABLE, INTEREST EARNED < TAXABLE LIMIT Date: _____________________

DECLARATION
FOR BANK’S USE ONLY
I/We agree to comply with the rules of the Bank in force from time to time governing the conduct of the For Customer profile refer to A/c opening form of
account and agree to be bound by them. Signature of introducer verified by ____________ SB/CA/C/FD A/c No. _____________

Opening of account authorised by ____________

Date ______________ ________________________
(Applicant’s Signature) Account opened by _______________________ Authorised Signatures recorded by _______
100X50 – 01/10 – KPP