Application for

NIC ASIA FCY Freedom Card (Prepaid Dollar Card)

For Bank’s Use Only -a}+s k|of]hgsf] nflu dfq_

Card No. -sf8{ gDa/_

Cust. ID. -uf|xs gDa/ _

Branch -zfvf_

Date -ldlt_ D D M M Y Y Y Y

Dear Sir/ Madam dxfzo,

For Issuance of New Card (First Time) gofF sf8{ hf/L ug{ -klxnf] k6s_
Please issue me FCY Freedom Card as per details given below:
s[kof dnfO{ lgDg ljj/0f adfl]hd lk|k]8 8n/ sf8{ hf/L ul/lbgx'fn
] f.

Card Type -sf8{ lsl;d_ FCY Freedom Card

Currency db
' f| USD -o='P;=8L_ Other FCY

Requested Amount

Account Holder’s Name -vftfjfnfs ]f gfd_

Designated Account No. -lglbi{6 ul/Ps ]f vftf_

For Replacement of Card k/

' fg ]f sf8s
{ ]f ;6\6f§go Ff hf/L ug{
Card Type -sf8{ lsl;d_ FCY Freedom Card

Currency db
' f| USD -o='P;=8L_ Other FCY

Please replace my / our Primary Card No.

sk[of d÷xfd| ]f k/'fg ]f kf|Od/L sf8s
{ ]f ;6\6f go Ff hf/L ul/lbgx'fn
] f

which has been Lost / Stolen / Expired / Damaged / Others

k/'fg ]f sf8{ x/fPsf] rfl]/Ps ]f cjlw ;lsPsf] ljus
]| ]f cGo

Account Holder’s Name -vftfjfns ]f gfd_

Designated Account No. -lglbi{6 ul/Ps ]f vftf_

PAN No. (Mandatory field)

Signature(s) of Account Holder vftfjfnfs ]f b:tvt

_____________________ _____________________

Authorised Signature Authorised Signature

-cflwsfl/s b:tvt_ -cflwsfl/s b:tvt_

b:tvt÷;r+fng lgbz
{] g kd
| fl0ft
For Bank Use Only as
+} Kfo|fh]gs ]f nflu dfq

_____________________ _____________________

Processed by Approved by
-ks
| o
[ f ug_{] -:jLst[ ug_{]
 Terms & Conditions -zt{ tyf aGbh
] x?_
Persons having individual account with NIC ASIA Bank Ltd. may avail NIC ASIA FCY Freedom Card under the following terms and conditions. These terms & condition shall
be deemed as agreement between the NIC ASIA Bank and the Cardholder. o; Pg cfO{ l; Pl;of a}+s ln= df JolQmut vftf ePsf JolQmx?n] lgDgfg';f/ zt{ aGb]hx?df /lx Pg=cfO{=l;= Plzof lk|k]8 8n/ sf8{ ;]jf k|fKt
ug{ ;Sg]5g\ . k|:t't ;t{ aGb]hx? o; a}+s tyf sf8{ jfxs ljrsf] ;Demf}tf dflgg]5 .

1. Bank means NIC ASIA Bank Limited, Card means FCY Freedom Card/ Prepaid Dollar Card issued to the Customer, ATM means Automated Teller Machine. Debit Card
means FCY Freedom Card/ Prepaid Dollar brand Card issued by the Bank Card Holder means authorized holder of Card, PIN means Personal Identification Number, POS
means Point of Sales. OTP means One Time Password. a}+s eGgfn] Pg cfO{ l; Pl;of a}+s lnld6]8, sf8{ eGgfn] u|fxsnfO{ hf/L ul/Psf] le;f÷le;f OG6/g]zgn 8]lj6 sf8{÷x? P=l6=Pd= eGgfn] c6f]d]6]8 6]n/ dl;g eGg] a'‰g'k5{ .
8]lj6 sf8{ eGgfn] a}+såf/f hf/L ul/Psf le;f÷le;f OG6/g]zgn a|fG8sf sf8{x?, x'g\ . sf8{ jfxs eGgfn] le;f÷P;=l;=6L÷le;f OG6/g]zgn 8]lj6 sf8{sf] cflwsfl/s jfxs, lkg eGgfn] JolQmut kl/ro gDj/, POS eGgfn] KjfOG6 ckm ;]N;, OTP eg]sf] Ps
;do kf;j8{ a'‰g'k5{ .

2. The Cardholder shall not use the Card for withdrawal of money from ATM Terminals and to pay for goods and services by using a card operated machine (POS) at
retailers or suppliers. The Card shall not be used for payments to capital business under any circumstances. sf8{ jfxsn] sf8{ a}w x'g] ljs|]tfn] k|of]udf NofPsf d]l;gaf6 a:t' tyf ;]jfsf] vl/b ug{
;Sg]5g\. o;/L hf/L ePsf sf8{ cgnfOgdfkm{t\ j:t' tyf ;]jf cfoft jfktsf] e'QmfgL ug{] k|of]hg afx]s k'FhLut sf/f]af/sf] nflu vr{ ug{ kfOg] 5}g . ;fy}, o:tf sf8{ k|of]u u/L ATM af6 gub lemSg], POS dfkm{t sf/f]af/ ug{] nufotsf sf/f]af/ ug{
;Sg]5}gg\.

3. The Bank shall debit the Account as designated by the cardholder for all the transaction and transaction charges initiated by using the Card. For this purpose, the
Cardholder irrevocably authorizes the Bank to debit his/her Nominated Account with the amount of transaction(s) plus any applicable charges levied by the issuer/acquirer
effected through the use of the Card. a}+sn] sf8{af6 ul/Psf ;Dk"0f{ sf/f]af/x? sf8{jfxsn] lglb{i6 u/]sf] vftfaf6 8]lj6 ug]{5 . o; k|of]hgsf] nflu sf8{ jfxsn] cfkm"n] lglb{i6 u/]sf] vftfaf6 sf/f]jf/ /sdsf] cltl/Qm sf8{ ;]jf k|bfg
ug]{÷k|of]u ug{ lbg] lgsfoaf6 nufPPsf] s'g} klg ;DjlGwt b:t'/x? 8]lj6 ug{ clVtof/L k|bfg ug]{5 .

4. The Bank shall debit the Nominated Account(s) for all the fees, charges and applicable interest, relating to card and card services. The Bank shall have discretion to
determine card issuance/replace/renewal/ re-pin charges along with administrative fees and other applicable charges as per standard tariff of charges (STC) which may
change from time to time. sf8{ tyf sf8{ ;Fu ;DjlGwt ;Dk"0f{ z'Ns, b:t'/ Pj+ nfu' x'g] Jofh lglb{i6 ul/Psf] vftfaf6 8]lj6 ul/g]5 . a}+saf6 ;do ;dodf k|sflzt x'g] sf8{ hf/L÷k'gM hf/L÷gljs/0f÷k'gM lkg nufot k|zf;lgs Pj+ cGo z'Ns÷b:t'/
STC adf]lhd lgwf{l/t x'g]5 .

5. The Cardholder shouldnot have taken dollar prepaid card facility from other Bank and Financial intuitions. This responsibility is fully that of the card holder. The
cardholder shall be punishable as per applicable law in force in case such instances are found. u|fxsn] PseGbf a9L Ohfhtkqk|fKt …sÚ ju{sf] a}+s / /fli6«o:t/sf …vÚ ju{sf ljsf; a}+sx?af6 o:tf] ;'ljwfsf]
pkof]u u/]sf] kfOPdf To:tf u|fxsnfO{ ljb]zL ljlgdo -lgoldt ug{]_ P]g adf]lhd sf/afxL x'g]5 .

6. The Cardholder shall provide all the bills, invoices, receipt and other required documents of international purchase upon request by the Bank. sf8{ k|of]ustf{af6 j:t' tyf ;]jf
cfoftafktsf] vr{ ePsf] /sdsf] aLn aLhs nufot cfjZos ljj/0f dfu ug{ ;lsg]5 / o;/L sfuhft nufotsf ljj/0f dfu ePsf] cj:yfdf u|fxsn] a}+snfO{ pknAw u/fpg' kg{]5 .

7. The Cardholder must take all reasonable precautions to prevent unauthorized use of the Card, including, not allowing anyone else to use the Card. The Cardholder is
solely responsible for maintaining secrecy of the Card Number (16 Digit Number) and Card Verification Value (3 Digit Code indented at the back) and shall ensure that the
same shall not be disclosed to any person either voluntarily, accidentally or by mistake. The card is issued on the condition that the Bank bears no liability for unauthorized
uses of the card. This responsibility is fully that of the card holder. sf8{ jfxsn] cgflws[t ?kdf sf8{sf] k|of]u tyf c?n] sf8{ k|of]u gug]{ ul/ ;Dk"0f{ ;fjwfgL ckgfpg' kg]{5 . sf8{sf] lkg sf8{ afxsnfO{ dfq yfxf x'g] ul/
uf]klgotf sfod x'gkg]{5 . cgflws[t k|of]udf a}+sn] s'g} klg bfloTj jxg ug]{5}g / o;sf] ;Dk"0f{ lhDd]jf/L sf8{afxs dfq x'g]5g\ .

8. The Bank reserves the right to cancel the Card and stop its operations unilaterally. The card is non transferable. sf8{ /4 ug]{ / o;sf] k|of]u aGb ug]{ Psf]xf]/f] clwsf/ a}+sdf lglxt x'g]5 . -sf8{
x:tfGt/0f cof]Uo x'g]5_ . sf8{ Ps JolQmaf6 csf]{ JolQmnfO{ x:tfGt/0f ug{ ldNg] 5}g .

9. Use of card after notice of withdrawal of privileges or the termination of the membership is fraudulent and may be subject to legal actions by the Bank according to
prevailing law. sf8{ ;b:otf ;dfKtL cyjf sf8{ ;'ljwf g/x]sf] ;"rgf kZrft\ sf8{sf] k|of]u 7uL / 5nk"0f{ ePsf]n] k|rlnt sfg'gdf /lx a}+sn] sfg"gL sf/jfxL ug]{ ljifo aGg ;Sg]5 .

10. The Card holder should immediately notify the bank in writing if the card is lost /stolen or the PIN is forgotten or accidentally divulged. Fresh Card/PIN shall be issued
in replacement of the lost/stolen card and forgotten pin at an applicable fee upon written application from request of the card holder. sf8{ x/fPdf rf]/L ePdf cyjf lkg sf]8 lj;]{df cyjf
b'3{6gfjz c?nfO{ yfxf ePdf sf8{ jfxsn] a}+snfO{ lnlvt ?kdf t'?Gt hfgsf/L u/fpg'k5{ . sf8{ jfxssf] lnlvt lgj]bgdf nfu' x'g] z'Nsdf x/fPsf, rf]/LPsf sf8{ / lj;]{sf lkgsf ;§fdf gofF sf8{ lkg hf/L ul/g]5 .

11. Wrong entry of PIN/OTP for three continuous times while making transactions in e-commerce will automatically make the card inoperative. In such case, the Cardholder
shall submit a written application to Bank for making the Card active again for operation. अनलाइनdf sf/f]jf/ ubf{ nuftf/ tLg k6s;Dd unt lkg sf]8 xfNbf sf8{ cfkm} k|of]u cof]Uo x'G5 . o:tf] cj:yfdf
sf8{nfO{ k'g k|of]u of]Uo agfpg sf8{ jfxsn] a}+snfO{ lnlvt lgj]bg lbg'kg{]5 .

12. The Bank shall issue a Card only if the applicant is an account holder of the bank and s/he has completely filled and duly signed an application form and it has been
accepted by the Bank. lgj]bs a}ssf] vftfjfnf ePsf] / sf8{ cfj]bg kmf/d k"0{f ?kdf el/ b:tvt eO{ a}+sn] :jLsf/ u/]sf] cj:yfdf dfq sf8{ hf/L ul/g]5 .

13. The Cardholder shall notify the Bank if: sf8{ jfxsn] lgDg cj:yfdf a}+snfO{ t'?Gt ;"rgf ug'{kb{5M
a. Any dispute or error in transaction is suspected. Such application shall include card holder name, card number, dispute date, dispute amount and description in written
form as prescribed by the bank within 30 days of such disputed transactions. The bank shall not be liable in case of financial loss to the customer if the dispute is not
reported within the said time frame. olb sf/f]jf/df s'g} ljjfb jf z+sf nfu]df sf/]fjf/ ePsf] #) lbg leq a}+sn] lglb{i6 u/]sf] kmf/ddf sf8{ afxssf] gfd sf8{ gDj/, sf/f]jf/ ldlt /sd ;lxtsf] ljj/0f k]z ug{'kg]{5 . olb tf]lsPsf] ;dodf
ljjfb jf z+sf nfu]sf] sf/f]jf/ a}snfO{ hfgsf/L gu/fP sf8{ jfxsnfO{ x'g] ljQLo gf]S;fg k|lt a}+s lhDd]jf/ x'g] 5}g .
b. The Cardholder’s address, telephone number is changed, as soon as possible. sf8{ jfxssf] 7]ufgf, 6]lnkmf]g gDj/ kl/jt{g ePsf] v08df oyf;So rfF8f] a}+snfO{ hfgsf/L ug{'kg]{5 .

14. If a retailer or supplier makes a refund by means of a transaction the Bank will credit the Account when it receives the retailer or supplier’s proper instructions and the
funds in respect of such refund, provided that the Bank will not be responsible for any loss resulting from any delay in receiving such instructions and funds. olb ljqm]tfn] jf
k|bfosn] sf/f]jf/sf] dfWodaf6 /sd lkmtf{ u/]sf] ;lx lgb]{zgdf dfq a}+sn] sf8{ jfxssf] vftf s|]l86 ul/g]5 . k};f lkmtf{ kfpg] qmddf ljs|]tf cyjf k|bfossf] l9nf ;':tLaf6 x'g hfg] s'g} gf]S;fgdf a}+s pQ/bfoL x'g]5}g .

15. The Bank reserves the right to put threshold on daily e-commerce transaction of the Cardholder. The Bank reserves the right to block the Card if the cardholder is found
to breach the threshold assigned or violate any of the terms and conditions or rules and regulations. b}lgs ?kdf a}+ssf] sf8{ l;df tyf gub ljj/0f lgwf{/0f ug]{ clwsf/ a}+sdf lglxt x'g]5 . tf]lsPsf] ;Ldf,
zt{ / Joj:yfsf] k|lts"n x'g] u/L sf8{af6 vr{ ul/Psf] kfOPdf To:tf] sf8{af6 sf/f]af/ ug{ h'g;'s} avt /f]s nufpg ;lsg]5 . ;Ldf, zt{ / Joj:yfsf] k|lts"n x'g] u/L sf/f]af/ ug{]x?sf] ljj/0f g]kfn /fi6« a}+sn] cfjZos h'g;'s} a]nf o:tf] ;6L ;'ljwf / sf8{
hf/L eO;s]sf] cj:yfdf ;d]t sf/f]af/ /f]Sg lgb{]zg lbg ;Sg]5 .

16. The Bank shall not be responsible in any way for non-availability of service at Merchant websites for any reason whatsoever or howsoever transaction failure or
otherwise. ljqm]tf :yndf sf8{ lau|]/ sfd gug]{ ePdf, Pj+ ;'rf?df ;d:of eP/ nufotsf s'g} sf/0faf6 ;]jf pknAw gePdf a}+s pQ/bfoL x'g] 5}g .

17. The Cardholder undertakes to indemnify the Bank and to keep the Bank indemnified against all losses, damages, cost or expenses incurred and sustained by the Bank
arising out of Cardholder’s failure to observe any of the terms and conditions mentioned herein. k|:t't aGb]h tyf ;t{x?sf] sf8{afxssf] ckl/kfngftfaf6 a}+sdf kg{ hfg] ;Dk"0f{ gf]S;fg Iflt cyjf vr{sf]
;f]wegf{ sf8{jfxsaf6 :jLsf/ x'g]5.

18. The Bank reserves the right to terminate membership, withdraw the privileges attached to the card at any time and to call upon the Cardholder to surrender the Card
without giving any reasons whatsoever. sf8{sf] ;b:otfsf] cGTo, sf8{;Fu ;DalGwt ;'ljwfx? aGb cyjf ldlt u'h|]sf sf8{sf] gljs/0f gug]{ / sf/0f gb]vfO{ sf8{ jfxsnfO{ sf8{ ;dk{0f ug{ af]nfj6 ug]{ clwsf/ a}+sdf lglxt x'g]5 .
19. The Cardholder acknowledges that s/he is familiar with and aware of the laws of the land and foreign exchange, Anti-money Laundering and Combating of Financing
of Terrorism regulations prescribed by regulatory authorities and agrees to comply with them strictly. The Cardholder is solely liable for voluntary or involuntary indulgence
in any illegal, money laundering or financing for terrorism activities using the Service; and indemnifies the Bank against any damages, claims or lawsuits or penalties arising
out of such involvement of the Cardholder including but not limited to prohibited goods and services. sf8{wf/s :jLsf/ ub{5g\ ls pgL hldg / ljb]zL ljlgdosf] sfg'g;Fu kl/lrt / ;r]t 5g\ = k|fKt
sf8{af6 sf/f]jf/ ubf{ k|rlnt lgod sfg'gn] lgif]w u/]sf j:t tyf ;]jf vl/b ug]{ 5}g / sf8{wf/ssf] To:tf] ;+nUgtfn] pTkGg x'g] s'g} Iflt, bfjL jf d'2f jf ;hfox¿ la¿4 a}+snfO{ Ifltk"lt{ ug{'kg]{5 = sf8{af6 sf/f]af/ ubf{ ;DklQ z'l4s/0f -dlg nfp08l/·_ lgjf/0f
P]g, @)^$ nufotsf k|rlnt sfg"g, lgod, lgb{]zgsf] k'0f{tofM kfngf ug'{kg]{5 / o;sf] ;Dk'0f{ lhDd]jf/L sf8{afxssf] dfq x'g]5.

20. If any provision of these terms and conditions becomes unlawful or unenforceable for any reason, the remainder of it will still remain enforceable. o; ;t{ tyf aGb]hdf pNn]v
ul/Psf s'g} aF'bf s'g} sf/0f ca}wflgs ePdf o;df pNn]lvt cGo zt{x?, a}wflgs /xg]5g\ .

21. Bank may from time to time add, amend, or change the above mentioned terms and conditions in partial or full and the Cardholder shall be unconditionally liable to
accept and adhere to all such additions, amendments and changes. a}+sn] pNn]lvt zt{ tyf aGb]hx?, ;do ;dodf cf+lzs cyjf k"0f{ ?kdf gofF j'bf yk, ;+zf]wg cyjf kl/jt{g ug{ ;Sg]5 . sf8{ jfxsn] s'g} zt{ /lxt ?kdf
o:tf yk ul/Psf, ;+zf]wg cyjf kl/jt{g ul/Psf zt{ aGb]hx? l:jsf/ / kl/kfngf ug'{kg]{5 .

22. The Bank shall not be responsible/liable for any fraudulent use of Card of the Card Holder due to his/her negligence. sf8{jfxssf] nfk/jfxLn] sf8{af6 hfn;fhLk"0f{ sfo{ ePdf a}+ssf] s'g} bfloTj
/ hjfkmb]lxtf /xg] 5}g .

23. The Cardholder shall, at all times, abide by the prevailing rules, regulations and laws and threshold limit of bank and central bank. If found any instances of non-com-
pliance with these policies, the bank reserves the right to block/cancel the card and may initiate legal action against the Cardholder. sf8{jfxs ;b}j a}+s tyf /fi6« a}+ssf] /sd lemSg] / cGo
gLltsf] clwgdf /xg]5g\ . olb ;f] cg';f/ gu/]sf] kfOPdf a}+sn] lghsf] sf8{ aGb ug]{ /4 ug]{ / sf8{ afxs lj?4 sfg"gL sf/jflx ug{ ;Sg]5.

24. The terms and conditions mentioned above shall become effective immediately after receipt of the Card by the applicant. pNn]lvt zt{ tyf aGb]hx?, sf8{ afxsn] sf8{ k|fKt ug]{ ljlQs} nfu'
xg']5.

25. Validity: j}wtf

a. Validity of the card shall be for 3 years and is not subject to automatic renewal upon expiry. sf8{sf] j}wtf तीन jif{sf] x'g]5, sf8{ :JftM gljs/0f x'g]5}g .
b. Card shall not be deactivated automatically by the system even if not used for 3 years before expiry. However, if customer’s bank account becomes dormant then the
card may not work until the account is activated. k|of]udf gNofP klg तीन jif{sf] a}w cjlw;Dd l;i6daf6 sf8{ :jtM lgl:s[o x'g]5}g . t/ olb vftf lgl:qmo ePdf vftf ;lqmo geP;Dd sf8{af6 sf/f]jf/ gx'g ;Sg]5.

26. All disputes, if any, arising out of or in connection with, or as a result of this Terms and Conditions or otherwise relating hereto, shall be subject to the exclusive jurisdic-
tion of the competent courts/tribunals in Nepal only. ;a} ljjfbx¿, olb s'g} 5 eg] oL lgod / ;t{x¿sf] kl/0ffd:j¿k jf o;sf] ;DaGwdf jf o; ;DaGwdf pTkGg ePsf] v08df dfq g]kfndf ;Ifd cbfnt ÷ Gofoflws/0fsf] ljz]if
clwsf/ If]qdf x'g]5.

27. Card can be used worldwide except Nepal, India and Bhutan. sf8{ g]kfn, ef/t / e'6fg afx]s ljZjJofkL ¿kdf k|of]u ug{ ;lsG5.

28. The Card can be used in both 3D Secure and non 3D secure Platforms. The Cardholder must take all reasonable precautions to prevent unauthorized use of the Card.
The Bank shall not be responsible in any way for loss, damages, etc due to unauthorized use of Card. sf8{ b'a} y|L8L 3D / u}/ y|L8L ;'/lIft Kn]6kmd{x¿df k|of]u ug{ ;lsG5. sf8{wf/sn] sf8{sf] cglws[t
k|of]u /f]Sg ;a} plrt ;fjwfgL ckgfpg' k5{. sf8{sf] cglws[t k|of]usf] sf/0f 3f6f, Iflt, OToflbsf nflu a}+s s'g} klg lx;fan] lhDd]jf/ x'g]5}g.

29. I declare that I understand the risk associated with this service and shall indemnify the Bank for any Card not present transactions conducted through my card shall
be liable to pay the Bank for any authorized/ unauthorized transactions. d 3f]if0ff ub{5' ls d of] ;]jf;Fu ;DalGwt hf]lvdnfO{ a'‰5' / d]/f] sf8{ dfkm{t ;~rfng ePsf] s'g} klg cflwsfl/s ÷ cglws[t n]gb]gsf] nflu a}+snfO{
e'QmfgL , Ifltk"lt{ lbg]5'.

Above terms and conditions shall be the integral part of the applications submitted by the applicant requesting for the issuance of Visa /Visa Int. Debit Card(s)/ FCY
Freedom Card. dfly pNn]lvt ;t{ tyf aGb]hx? le;f÷le;f OG6/g]zgn 8]lj6 sf8{ / 8n/ lk|k]8 sf8{x? hf/L ug{ lbPsf] lgj]bgsf] cleGg efu xf] .

I have read and understood the terms and conditions overleaf and agree to abide by them at all times. d}n] dfly pNn]lvt zt{ tyf aGb]hx?, k9] / a'Fem] / ;b}j ;f] cg'?k ug]{ d+h'/L lbG5' .

Card Department

NIC Asia Bank Ltd.

Authorised Signature
Trade Tower Nepal
-cflwsfl/s b:tvt_
Thapathali, Kathmandu, Nepal