Annexure A
Branch Name: D.NO:
MERCHANT ESTABLISHMENT APPLICATION FORM (BHARAT/BHIM QR CODE & UPI123)
BHIM QR Bharat QR Sound Box Standee Sticker ID Card UPI123
1. Name of the Merchant Establishment:
2. Constitution of the Firm: (Please √ at appropriate column)
Individual Sole Proprietor Partnership Firm Limited Company (Pvt./Public)
Public Undertaking Co-Op Society Govt. Establishment Others
3. Merchant Establishment Address (Installation):
City
State PIN
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4. Name of Proprietor/Partners/Authorized Signatory(ies)/Director(s) of the Firm:
Residential DIN (In case
Name Designation S/o / W/o Address PAN Card No. ofLimited
Company) ^
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^DIN – Director Index Number
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5. Details of the Account Holder:
*Account No.
*Funds will be transferred to above mention merchant Account.
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Mobile No: (Registered with the Bank for receiving SMS alerts):
Email ID: (I authorize Bank to update below Email Id in my above-mentioned Account Number)
6. Particulars of Registration with Statutory Tax Authorities:
Income Tax PAN No. (Co./Firms/Individual/Proprietor/ Authorized
Signatory)
GST No.
7. Nature of Business (Goods & Services Offered):
8. Previous Year/Estimated Turnover
9. No. of Agents/Operators
(Single BHARAT/BHIM QR Code will be generated for the Merchant using his/her above registered mobile number. However, if
merchant wants to have QR Code specifically for its operators then enter number of Agents/Operators.)
10. Details of Operators/Agents (if any): (Separate BHARAT/BHIM QR Code will be generated for each Agent)
S.No. Agent Name Mobile Number S.No. Agent Name Mobile Number
1. 9.
2. 10.
3. 11.
4. 12.
5. 13.
6. 14.
7. 15.
8.
11. Name and Residential Address of Principal Contact Person:
City
State PIN
Telephone No: (with STD Code) :
12. Are you existing customer of PNB: Y/N:
If yes, period of relationship:
13. Please select additional modes of accepting payment via UPI (MDR applicable on below):
Credit Card on UPI Unsecured overdraft Prepaid Wallet Other ………………….
DECLARATION
➢ I/We confirm that the information given by me/us is true and complete and forms the basis for
enrolment as a member of the Punjab National Bank Merchant Establishment.
➢ I/We undertake to enter into transactions only in relations to goods sold or services provided by me to
the Customer and not enter into a third-party transaction or dispense cash by processing a Transaction
➢ I/We agree to pay Merchant Discount Rate (MDR) applicable from time to time to PNB.
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➢ I/We shall abide by the terms and conditions of PNB Bank stipulated from time to time.
➢ I/We confirm that transactions carried out under BHARAT/BHIM QR Code/UPI123 are legitimate
merchant transactions and PNB assumes no responsibility for any consequences arising out of such
transactions.
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➢
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I/We further declare that I/We have read and agreed to be bound by the terms and conditions
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mentioned in the Annexure-I.
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(Signature of the Individual/Proprietor/Partner/Director/Authorized Person (s) with Stamp)
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Full Name: Full Name:
Designation: Designation:
Place: Place:
Date: Date:
(If there are more than one authorized signatory, all the signatories must sign this application form
giving details of full name and Designation)
FOR PNB SOURCING BRANCH
We have verified the signature of merchant establishment/Authorized Signatory (ies) as per Bank record. The
application form along with KYC documents of the Merchant Establishment/Authorized Signatory (ies) as per
KYC/Bank’s guidelines has been checked and verified and kept at Branch for record. We recommend for providing
BHARAT/BHIM QR Code to the Merchant Establishment M/s
A/c No
IFSC
MCC Code
Sub code
Place: Signature of Officer/Manager/Branch In-Charge
Date: (With Bank Stamp)
BO:
Sol ID:
GBPA/P.F:
Annexure-I
TERMS AND CONDITIONS FOR MERCHANTS USING BHARAT/BHIM QR CODE & UPI123
The Terms and Conditions mentioned hereinafter shall be effective upon submission of the merchant
enrolment application form to PUNJAB NATIONAL BANK and will govern the relationship between the
merchant and PNB including its Service Provider for the use of BHARAT/BHIM QR CODE/UPI123.
I/We agree with the terms and conditions hereunder:
1. I/We shall display the BHARAT/BHIM QR Code/UPI123 issued by the Bank at a conspicuous place where I conduct
the Business.
2. I/We hold valid and subsisting licenses, permits and consents required for the conduct and operation ofthe Business
from appropriate Government(s)/Local Bodies/Competent Authorities.
3. I/We undertake to abide by all the laws and regulations as applicable to it. I/We shall, when requested by a
Customer, facilitate a transaction in accordance with the terms and conditions and including the procedure stated as
may be amended by the Bank from time to time in writing.
4. I/We undertake to enter into Transactions only in relation to goods sold or services provided by me to the Customer
and not enter into a third-party transaction or dispense cash by processing a Transaction.
5. I/We undertake that I/We will be responsible for all risks associated with the delivery of the products and/or services
by me. Any and all disputes regarding quality, merchantability, quantity, non- delivery and delay in delivery of the
products and/or services or any other dispute of like nature shall be resolveddirectly between me and the Customer
without reference to the Bank and I/We shall always keep the Bank indemnified in this respect and in case Bank has to
pay to Customer then Bank may recover the amount from Merchant.
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6. I/We acknowledge and agree that the sale of goods and services under the transaction shall be betweenme and the
customer without the Bank being a party thereto.
7. I/We shall be charged Merchant Service Fee as per application form ( by capping it as per RBI Mandate) and
Minimum balance charges as per NPCI/ RBI/UIDAI (Unique Identification Authority of India)/bank’s guidelines and will
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follow all guidelines of NPCI/RBI/UIDAI/Bank regarding BHARAT/BHIM QR Code/UPI123 system and the said charges will
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be reviewed and revised as per GOI/NPCI/RBI/Bank guidelines.
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8. I/we shall be charged by the bank for the aforesaid products as applicable from time to time.
9. I/We shall inform Bank regarding any change in constitution/composition/ownership & commercialactivity.
10. I/We shall report promptly to Bank, a fault or suspected fault in the operation of the BHARAT/BHIM QRCode/UPI123
and any fraudulent or suspicious transaction.
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11. I/We shall provide all reasonable assistance to Bank for the prevention and detection of fraud in respectof usage of
BHARAT/BHIM QR Code/UPI123.
12. I/We shall keep all the information received from the Bank in connection with BHARAT/BHIM QR Code/UPI123
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confidential and not disclose it to any person other than my/our staff member(s) connected with the operation of the
BHARAT/BHIM QR Code/UPI123 system for effecting payments through it.
13. I shall enter into transactions in Indian Rupees only.
14. While presenting any transaction information, I/We certify to the Bank that (i) all statements of facts contained
therein are true and complete in all respects, (ii) have supplied goods or services to which the transaction information
relates and to the value stated therein and at a price not greater or not lessfavorable than the same price and terms at
and on which such goods or services are supplied by mefor cash, (iii) the Transaction information pertaining to each
sale has been supplied only once, and (iv)that the sale of such goods or services are not unlawful or prohibited.
15. I/We will be solely responsible and accountable for reasonable and prudent care in handling the BHARAT/BHIM QR
Code/UPI123.
16. I/We understand that, in the event of any goods are not received by a customer or are rejected pursuant to non-
compliance by me or pursuant to any terms of contract between me and the customer or are otherwise lawfully rejected
or are accepted for return and/or services paid for by the customer are not performed or are cancelled by me or the
price is lawfully disputed by the customer or the price adjustment is disputed by me/us,
➢ shall not make any cash refunds to the such Customer;
➢ make all refunds to the Customer through the Bank as per the process communicated by the Bank;
➢ Forthwith make payment of the amounts to be refunded to the Bank for onward credit to the Customer.
17. In the alternative, the Bank may at its option adjust all such amounts from the amount payable by it to me or provide
for such other procedure for refund in writing, as the Bank may deem fit from time to time.
18. I/We expressly agree for the inclusion of my Merchant establishment’s name in any directory or promotional
material produced in connection with the BHARAT/BHIM QR Code/UPI123 and to prominently display and maintain the
Bank's Promotional Material as supplied by the Bank from time to time.
19. I/We indemnify the Bank and their authorized representative in respect of any, actions, claims, costs, damages,
demands, expenses, losses, penalties, fines, assessments and injuries made against, suffered or incurred by any of them,
including reasonable attorney's fees, arising directly or indirectly from or in connection with my statutory and regulatory
obligations as well as any dispute between the Merchant Establishment and the Customer.
20. I/We shall not misuse the BHARAT/BHIM QR Code/UPI123 issued by Bank including unauthorized access, replay
attack, shifting, hacking, cracking etc.
21. I/We shall not temper Hardware/Software and/or hard copy of BHARAT/BHIM QR Code/UPI123 provided by the
Bank.
22. I/We shall not, without the prior written consent of the Bank and the Customer, use or disclose the nameor any
other information of the Customer, to a third party unless such disclosure is compelled by applicable law.
a) I/We undertake that any information of the Customer available with me shall only be used forthe
purpose for which such information was provided to me.
b) I/We undertake to take all steps as may be reasonably necessary to protect the integrity ofthe
Information and to protect against any unauthorized disclosure thereof;
c) promptly inform the Bank of any potential or accidental disclosure of the Information andtake all
steps, together with the Bank, to retrieve and protect the said Information;
d) ensure that the employees and/or representatives of the Merchant Establishment who are given
access to the Information shall at all times be bound by and comply with legally valid and written
non-disclosure obligations under their employment contracts; and
e) Use the Information only for the purpose for which it was provided and shall not earn profit from
the same in an unauthorized manner to the exclusion of the Bank.
23. I/We shall not allow unauthorized access, transmission and/or use of data or the damage, erase, copying,
disruption, alteration, corruption, loss, theft, degradation, dissemination, and/or distribution of a data in any
manner.
24. I/We understand that the Bank reserves the right to amend the terms and conditions. Any such amendment
shall be effective and binding on me upon notification received by ordinary post/mail/any other mode and if I
am unwilling to accept any such amendment, I/We shall notify the Bank in writing by registered post within
seven days from the receipt of the notification by the Bank. Failure to receive the notice shall be deemed as an
acceptance of the amendments to the Terms and Conditions by me.I/We shall provide necessary support to Bank
and its Service Provider in connection with use of BHARAT/BHIM QR CODE/UPI123 and shall comply with all
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necessary instruction given by them.
25. I/We understand that the Bank shall, towards authorized transactions complete in all respects, pay to me by
crediting my account with the Bank, the amount of Transactions net of (i) the merchant Commission, computed
at the rate (as per RBI Mandate), of the Transaction Amount plus
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applicable taxes and ii) any other amount due by me to the Bank.
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26. I/We understand that the Bank shall endeavor to make payment of amount when due to me on transactions,
within T+1 business days after receipt of the transactions by the Bank. Payment collectedby Merchant and his/her
agent(s) using his/her BHARAT/BHIM QR Code/UPI123 will be credited in the merchant account only.
27. I/We understand that the Bank shall be entitled to set off and deduct from the amount payable to me,
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(1) The amount of refund due to any Customer in accordance with the procedure for refund, (2)
Overpayment made by the Bank due to errors or otherwise, (3) Any taxes or claims required to be paid
under law or in terms of the directions of any regulatory or legal authority and 4) Chargeback amount.
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28. I/We understand that the Bank has a right to recover any transaction value, if charge back is created from my
account/ future payment or hold payment of any disputed transaction and Bank will not be responsible for any
chargeback, payment hold, transaction failure, loss, fraud etc. for any reason whatsoever.
29. I/We understand that the Bank assumes no liabilities in respect of failure of transactions attributable to other
entities.
30. I/We understand that the Bank reserves the right to suspend /terminate the services provided under
BHARAT/BHIM QR Code/UPI123 system.
31. I/We will make ensure that the BHARAT/BHIM QR Code/UPI123 will be used for the purposes as provided or
intended.
32. I/We agree to retain sufficient fund in my bank account to cover the entire amount that are due by me to Bank,
including losses.
33. I/We will be responsible and accountable for proper and prudent maintenance of required necessary documents
with regard to transactions and shall furnish these documentations to Bank, whenever required by Bank.
34. I/We shall not use the Bank’s name, trademark, or trade name, in publicity releases, advertising or anyother
manner.
35. I/We understand that the Punjab National Bank may from time to time give any credit and other information
about me/us, including information on this form, to or receive such information from any credit bureau,
reporting agency, person with whom I/We may have or propose to have financial dealings.
36. I/We agree that the Punjab National Bank may use this information to establish and maintain my/our
relationship with the Bank and to offer any services as permitted by law.
37. I/We authorize the Bank to verify my/our credentials or make any references required in respect of enrolment
as a Merchant Establishment of Punjab National Bank.
38. I/We understand that in case of change of registered mobile number in my account, the BHARAT/BHIM QR
Code/UPI123 issued by the Bank may be de-activated by the Bank.
39. I/We understand that the Bank reserves the right to take any legal action on me in case of breach of any of
above-mentioned terms and conditions and these term and conditions are subjected to the exclusive jurisdiction
of the Courts/Forums/Tribunals in Delhi only.
Date:
Name & Signature of Merchant/Authorized Signatory (ies)
(With Rubber Stamp)Contact No.:
