Customer Consent Form

Customer Details

CCF No. :

Applicant’s Name : 

(IN BLOCK LETTERS) 
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Date of Birth : 

DD MM YYYY

Letter of Consent

I have applied for the Citibank Credit Card** via the [ ] Phone / [ ] Internet Channel and have read the
Most Important Terms and Conditions (MITC) pertaining to the credit card shared with me (as a physical copy
via post/ over email/ on the Citi website while submitting the online card application)

I hereby confirm that I have applied for a Citibank Credit Card through the above channel. I understand that the
card will be issued at the sole discretion of the Bank and is subject to its credit processing criteria. I hereby
understand and agree that it is my responsibility to obtain, read and understand the terms and conditions
related to the Citibank Card as applicable from time to time. I further authorize Citibank and/or its
associates/subsidiaries/affiliates to verify any information or otherwise at my office/residence and/or contact

me and/or my family members and/or my Employer/Banker/Credit Bureau/CIC/RBI and/or any third party
as they deem necessary and/or to do any such acts as they deem necessary. I agree to the Authorisation
Statement which was communicated to me at the time of card application and I undertake to comply with the
card terms and conditions and applicable laws from time to time.

Customer Signature : _______________________________________________________

Date : _______________________________________________________

** For more information on your product kindly visit our website: www.citibank.com/india. Alternatively, you can also
call our 24 X 7 CitiPhone help line at – 1800-22-2484 (CITI)

Citibank and Arc Design are service marks of Citibank, N.A. or Citigroup Inc., used and registered throughout the world.