Sampath Credit Card eStatement Enrolment Form

iïm;a Kh ldâm;A e m%ldYk i|yd we;=<;a ùfï wdlD;s m;%h

rk;gj; fld; ml;il e $w;W Nru;j;Jf;nfhs;sw; gbtk;

Card Number(s)
Kh ldâ m;a wxlh ^wxl&
ml;il ,yf;fk;(q;fs;)

Cardholder’s Name
ldâ m;a ysñhdf.a ku
ml;ilitj;jpUg;gtupd; ngau; ..……………………………………………………………………………………………………………………………………….

Email Address
úoAHq;A ;eme,A ,smskh
kpd;dQ;ry; Kftup ……………………………………………………………………………………………………………………………………….

Your Signature is proof of having read and understood the following:

Tnf.a w;aik my; i|yka lreKq lshjd wjfndAO fldg f.k we;s njg jQ idOlhla fõ'
ckJ ifnahg;gk; gpd;tUtdtw;iw thrpj;J tpsq;fpaikf;F vz;gpg;ghFk;.

Terms & Conditions of SAMPATH BANK PLC for Cardholder availing the eStatement The Service
In consideration of SAMPATH BANK PLC (hereinafter referred to as The Bank) agreeing to accept my request for sending my monthly statements to my email address, I hereby agree that all
statements whether through eStatement service or other means of transmission sent by The Bank for my Card shall be accepted and upheld by me as correct and authenticate. I declare that I
shall not raise any objection against The Bank on its agreeing the same and fully accept the risk and responsibility of state ments transmitted by The Bank via electronic mail. I agree and
acknowledge that The Bank does not warrant against any external factors affecting the privacy and /or security of emails duri ng internet transmission. I also agree to keep The Bank indemnified
against all actions, proceedings, liabilities and claims, cases, damages, costs and expenses in relation to or arising out of so accepting my request by The Bank and The Bank transmitting
statements and information through email. I further agree to pay all fees and charges, which The Bank may impose from time to time in connection with the service in the manner stipulated by The
Bank. I also authorize The Bank to add, discontinue or vary any of the service from time to time without any notice to me. I assure The Bank that I shall inform in writing of any change in my email
address or any request for discontinuation of this facility to The Manager, Card Centre, Sampath Bank PLC, No 110, Sir James Peiris Mawatha, Colombo 02, Sri Lanka. I further expressly
agree and acknowledge that The Bank shall not be liable or responsible for data corruption, delay and/or interception of the information so given and that The Bank reserves the right to update
and vary such information from time to time and at any time. I also authorize The Bank to send advertising and Promotional Materials to my email address through email, the promotional window
of the service. I declare and confirm that this agreement shall be treated as or deemed to be an integral part of the Credit Card Agreement that I have executed with The Bank and that all other
terms and conditions of the Credit Card Agreement that have not been changed or modified by this agreement shall remain in full force and effect.
e m%ldYk fiajfhys i|yka ldâm;a ysñhd i|yd m%fhdackj;a jk iïm;a nexl=j mS t,a iS wdh;kfha kshuhkA yd fldkafoais my; oelafjk mßos fõ'

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fj; jeä ÿrg;A n,h mjrd isákq ,nhs' fuu .súiqu nexl=j iu. ud úiska ,shd w;aika lrk ,o fl%äÜ ldâ .súiqfï m%Odk fldgila f,i i,lkq ,eìhhq;= fyda woyia lrkq
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Signature (As in Card Application Form) Date

w;aik ^Kh ldâm;A b,a¨ï m;%fha i|yka mßos& oskh
ifnahg;gk; (ml;il tpz;zg;gg; gbtj;jpw;Nghd;W)…………………………………. Jpfjp…………………………
Sampath Bank PLC – Card Centre
110, Sir James Peiris Mawatha, Colombo 02.
: 011-2300599 Lost Card report (24Hrs) : 011-2300598
General Inquiries
: 011-2303075, 011-2303076 Fax : 011-2300603, 011-4712013
Billing Inquiries Website
: 011-2300598, 011-2300604 (24 Hrs) : www.sampath.lk
Card Inquiries Email
PIN Inquiries : 011-4730371 (Office hours only) : card_center@card.sampath.lk