To, Date:

The Head of PBD Cardholders Request Form

Jamuna Bank Limited
Personal Banking Division
Head Office: Hadi Mansion
2, Dilkusha C/A, Dhaka 1000

Through: The Manager, .Branch.

Dear Sir,
I do hereby request for the following thing(s) [(tick(s) is/are placed in the appropriate Box (es)]:

Issuance of replacement Card Lost/Stolen/card close

Incorrect Name/Spelling mistaken on Card
Wrong Photograph on Card
Cards is physically damaged
Magnetic strip error
Others (pls. specify)
.
Reactivation of Blocked Card Incorrect PIN entered at ATM or POS Terminal
Blocked over phone
Others (pls. specify)....
......
Reissue of PIN Lost/Stolen
Forgotten
Others (pls. specify)
.
Linkage of Account Number: 1) , 2)

Moreover, I declare that I am aware of the fees & charges as mentioned overleaf for the aforesaid request(s) made by me
against my JBL Q-cash, VISA Debit Card/VISA Credit Card, My full Name, Account Number & Card Number are below:

Name :

Account Number :

Card Number :

*Printed Name :

*Fill in this Box if your name is Incorrectly Printed on the card. Cardholders Signature
For Branchs use Only:

Cardholders signature is verified &

Recommended for taking necessary action. Signature of the Branch official with PA
Number & Branch Seal.
For PBD use Only:

Action is taken as per customers request Signature of the Authorized Officer