Card Statement and Payments Page 1 of 4

cíti

Reqyest ID A0002532034

CItbank Cardholder Applcatlon Form - Commercial Cards

Citibank Cardholder Application Form- Commercial Cards

Citibank Information
1
Program Name BOEING INDIA PVT LTD VISA
Select the Biling Account Numter
4645582001027572- BOEING INDIA SERVICES-LK
2 Billing Account Number - based on the information
provided by your Implementation
Manager
3. Plastic flag

Cardholder Personal Infommation

(e.g. Mr, Mrs or Ms)
1. MR
Title
Please provide your first name as
2. First Name devraj per PANGN Card
Please provide yOur middle rame
3 Middle Name as per PAN Card
devraj dash Your name as you would like it to
4. Embossed Name on card appear on your card- Maximum
19 characters (No special
Characters). Please note that your
name will appear in upper case on
your Coporate Card
Please provide your last name as
5. dash
* Last Name per PAN Card

6. Gender
MALE
18/08/1985
7 Date of Birth
8 INDIAN
Nationality
9 Place of Birth
10 Ambika Rath
Mother's Maiden Name
11. *Home Address Line 1 Flat No AG02 sekhar bellevue

12 Home Address Line 2 balagere road bangalore

13 Home Address Line 3

14 Home City Bengaluru

15 Home Country INDIA

16 91-888-2724-905 country code(91) - state

*Home Telephone code(ZTD Code) - number -
extension
17 Home Postal Code 560087

18 91-8882724905 Please provide your 10 digit India

Moblle Phone mobile number.You will be
receiving SMS transaction alerts
and you willrequire to get OTP for
all online transactions.
19 Email Address [email protected] This will assist Customer Senvices
should we need to contact you
urgently regarding your card
account

Cardholder Employment Information

Card Statement and Payments Page 2 of 4

1 003494279
" Employee ID
2 " Business Address Line Boeing India Prlvate Limited Pleane ingut your Company name

3 Business Address Line 2 Loko Viw Bullding, A Block, 0thh Floor,

4 Business Address Line 3 Bagmane Tech Park, CV Raman Nagar

5
" Business City Bengaluru
6 " Business Country INDIA

7 Business Postal Code 560093

91-880-2724-905 country code(91)-state

" Business Telephone code(STD Code) number
exlension
Please indicate here yur Cost
Cost Center Centre, whicth will assist wth yeas
organisation's repning prpSAS
Cost Cerntre Descrigtion
10 Cost Center Desciption
11. Department name
12. Embossing Company Name BOEING INDIA
In case you are not ure abt he
13. Reporting Unit 000001003 BOEING INDIASERVICES-LK a I olegse cotact yGUT
ReporingAdministrator
Program Dp
Incase you are receivinga paper
14. " Deliver Bill To Business statement, it would be send only
to your business address.

15. "PAN Number XXXXXX433F

This will assist Customer Serices
16. Deliver Mail To Business should we need to contact ycu in
writing regarding your card
account. lease note, Citi do not
endoui direct marketing
Communications
Please indicate here if you would
17. " Deliver PIN To Business like us to send your Cití Corporate
PIN to your business address or
to compary Primary PA.
Please indicate here if you woukd
18 Business like us to send your Citi Corporate
"Deliver Card To
Card to your business address or
to company Primary PA,
Please select a 6 Digit PIN. AI
19 * PIN numbers in the PIN can't be same
(i.e. 222222), cannot be
sequential, ascending or
descending i.e. 123456, 654321.
DOB or other national
identification numbers shouid not
be used.
Please select a 6 Digit PIN. AII
20. *Confimm PIN numbers in the PIN can't be same
(i.e. 222222), cannot be
sequential, ascending or
descending i.e. 123456, 654321.
DOB or other national
identification numbers should not
be used.
ONLY ONLINE STATEMENT
21. * Statement Option

Cardholder Limit Detalls

Please indicate here if you wish
1. Single Transaction Limit for the cardholder to have a
single
transaction limit - this is the
maximum amount allowed of any
single transaction.
2 Monthly Credit Limit 2400000 This is the monthly spent limit to
be applied to the card.
3 200000 Please indicate cash withdrawal
Monthly Cash Limit limit if you wish the cardholder to
be withdraw cash (if cash
val is avalled for the
company).
4
Cash Replenishment Daily If there is no Monthly Cash Limit
indicated, please leave blank.
Frequency Select We ay f youwish to
further limit o O h a lon
Such frequency select
Monthly.
5 Cash Replenishment 200000 Please indicate amount if you
have selected Cash
Frequency Amount Replenishment Frequency as
DailyWeekly/Monthly. swill be
the maximum amount cardhoder
can withdraw in specified period.
6 Daily Cash Count
990 Please indicate if you wish toof set
aOunh
daily onthe number
cash access (if cash
access is provided).
Card Statement and Payments Page 3of 4

CITIBANK CARDHOLDER ACCOUNT AGREEMENT

Conditons of use (COU)

,the cardholder, acknowiedge thal all infomalon on this applicallon is (ruo and correct. ard upon use of my card. Iunderstard that it is y resprstaity
to notify Citibank inmediately if my card is lost or stolen, Iacknowledge that my Company will be llable for payrnent of al|lransacions made with my card
and Iconsent to the disclosure of infomation relating to me to the Company. By submillng this applcation, Iathortze you to intrn my employer
Company whether this application has been denied or approved. Icongent to the collecllon, Use anxd disclosure o rny personal data in accordanCe with
the applicable IT law and regulations (T Regulations") the manner set out in the Privacy Clrcular. I further authorlze the lransler and disckosura cf
infomation relating to me, to the my Company ( including the card Program Admirnlstrator), to and between branches, subsidiarles, representatie oices,
affiliates and agents of Citibank and third partles selected by any of them, wherever sltuated, for confldantial use (including lor use in connectian with the
provision of credit card services). Additionally, I understand that Intomatlon, as requlred under lw or any applicable regulation, and at the order od a cat
of law, or at the request or order of any stalutory, regulatory or supervisory authorlly with whom Citlbank custormarily complies, shall be disclosed.
Infomation and data relating to my Company the Customer, Accoun/s,Cards and Cardholders lIke me including b°t not limited to associated infcrmation
and information relating to default, if any,may be disclosed and furnlshed, to the Reserve Bank of India ('RBI) and/or to the Credit Information Bureau
(India) Ltd. and/or to any other agency authorized in this behalf by RBI, to service providers, professional advisers and consultants of Cibank. Further,
warrant that in respect of the personaldata of any other individual that I may furnish to you, (A) lam authorized to consent, and hereby consent on such
individual's behalf, to the collection,use andlor disclosure of his personal data as described above and/or in the IT Regulations Privacy Circular, andlor (E)
Ihave provided notice to, and have obtained consent from such persons to allow Ciibank to process their personal data as descríbed above andlor in the
IT Regulations Privacy Circular, prior to disclosure of such personal data to Citibank.

Note to Applicant
PLEASE READ THE NOTE TO APPLICANT INSTRUCTIONS BELOW

Mandatory Details to be included with the Application are as below:

Attach a Black &White visible photocopy of Pemanent Account Number (PAN Card): duly sell-attested by the Card Applicant
Recent Passport-sized color photograph to be afixed on Card Application Fom
First Name, Middle name &Last Name of the Applicant mentioned on the form should be match as per PAN Card copy.
Application will be processed only if all mandatory documents and mandatory fields are updated.
For submission, please follow either of the below options.

Option 1: If Citimanager Library folder is created for your Company and the Program Administrator is granted access, please engage your Program
Administrator to upload the mandatory documents under the Citimanager Library folder indlcating the Name of the Aplicant as Document Tile" and
Request ld as "Description".

Opion 2: Please print a single sided copy of this Application Fom, card applicant to sign on it.
Send your signed application form with mandatory documents to Citi branch mentioned below:

Commercial Card Operations. Cititbank N.A. 12nd Floor, Ranga Complex | No. 5, M.G. Road | Bangalore - 560001.
Commercial Card Operations, Citibank N.A,Nimal Building, Ground Floor, Barrister RajaniPatel Marg, Next to Express Tower, Nariman Point, Mumbai
400021.

Commercial Card Operations. (A) 5th Floor, DLF Square Building | Jacaranda Marg | DLF Phase 2 | Gurugram 122002 | Haryana | India
Credit card will take at least 8-10days to reach your mailing address after submission of application form and KYC documents at Citi branch.

Citibank, N.A, India Branch

APPLICANT NAME AND SIGNATURE:

Iconsent to Citibank International plc transferring and disclosing my personal data in the ways outlined in the Data Protection Notice.

I, the undersigned, hereby request the issue of a Card (and replacement on expiry) and PIN exclusively for use in connection with the business of my
employer and, if different, the entity at whose request the card is to be issued. I consent to the processing of my personal data as described in the Data
Protection Notice. Ideclare that the details above are true and complele.

Applicant name: DEVRAJ DASH

Position Held in Company: Mechandee-Hydraulis ngineer
O0l 2024
Date(DD/MMYYY:
Signature:
eyDast
INCOME TAX DEPARTMENT SGOVT. OF INDIA

Permanent Account Number Card

AWJPD8433F

DEVRAU DASH
16012018
RHIFathersName
RAMESH CHANDRA DASH SHARMA

18/08/1985