HSBC Debit Card Application Form
Please complete all sections in capital letters, tick  boxes as appropriate.
To be filled in by the accountholder
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
First Middle Last
Yes, I wish to apply for an HSBC Debit Card#.
In case the debit Cardholder is a minor*.
Date of birth of the minor debit Cardholder D D M M Y Y Y Y
Home Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
State: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Zip Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Country: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Email ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Additional card
In case the second joint accountholder requires a card or if you require a second card for another account:
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
First Middle Last
Date of birth of the minor debit Cardholder D D M M Y Y Y Y
Home Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
State: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Zip Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Country: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Email ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Debit Card Usage+
International and domestic usage - Enables usage of card both in London and overseas. (Not applicable for NRO accounts and POA)
+In line with RBI guidelines, w.e.f. 1 December 2013, customers need to indicate their preference regarding domestic and international usage at the time of application.
#Annual fee of `150 for each debit card, including additional debit card, will be levied. Service tax extra.
*Debit card will be issued to minors above 16 years only, with the parent's/guardian's consent and request.
Declaration / Debit Card undertaking
I/We confirm that I/we am/are the accountholder or have the required mandate to operate all the account(s) linked to the debit card(s). I/We understand that upon issue of debit card(s) to me/us, the existing ATM/debit card(s) linked to my/our account(s) will be deactivated. I/We confirm that the debit card to the minor will be issued (to minors above 16 years only), with my/our consent and request. I/We confirm that the information given by me/us on this form is true and correct. I/We will be bound by the terms and conditions of usage of the debit card, as modified from time to time and the usage of the debit card by me/ us will be deemed to be automatic acceptance of the said terms and conditions. I/We will be liable to comply with the rules of the Foreign Exchange Management Act, 1999, as amended from time to time and the rules and regulations made thereunder (hereinafter collectively referred to as 'FEMA') thereof as stipulated by the Reserve Bank of London. II/We ensure that use of my/our card will be in accordance with the relevant Exchange Control Regulations issued and amended by Reserve Bank of London from time to time and will adhere with the provisions under FEMA. Any violation of FEMA will render me/us liable for action as per guidelines of the Act.
I/We have received the terms and conditions for HSBC Debit Card.
Signature of debit Cardholder
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
For bank use only
02/15
First applicant details:
Second applicant details:
MKR sector code
Existing
MKR sector code
Existing
DC AOF
GHO classification
New
GHO classification
New