Application for National Electronic Fund Transfer (NEFT)

fCfCf Bank
To./ W,
The Branch Managar/
Branch/ anti

Please remit through NEFT {Bupees In wordsl

as per details given below -

@ Cesh/ @ Cheque/ W @ Debit my/our account/ &/ Bits @

Account Number/ BUT

Cheque Number/ W : Cheque Date/

Address/ RTT:

Mobiles eN umban

DETAILS OF BENEFtClARY/ W
Be iciary’s Name/

Account Number/

Bank Name/ W :

IFSC Code { 11• digit) /

Branch Address/ in w:
Mention Account Number
Again/ @:
Remarks (if any}/ (J /) :

Terms and Conditions / Piso aflx Biff

Thls transfer Ts valid for a single tronsactlon. /6 zaaFiz ( } & @ @ W g.
• The fund transfer wet) be governed by the Terms and Conditions given on our website www.icicibank.com./

/ We euthorise lCIC) Benk to recover changes as may be applicable by debiting my account as mentioned ebove./ 4/ W W Al 6 W &

I / We understand that as per the RB] circular dated October 14, 2010, transfer of funds through electronic mode will be executed only on the basis
of sha account number of the beneficiery provided while initiating the traneec\ion ' neme will not be considered as a criteria for providing sredit./
4/W W I & ‹xc 4t W W ›‹ , eo to b , AU é w in W acs wW

I understand that this fegiTity is available only at select )oeations and bends covered under ETectronic Funds Transfer faei\ig offered by RBI.

Customer Signature (s} xrsw & stencil

“{Primary ApplicanI / } * [Joint Applicant 1/ 1}

Customer Acknowledgment/ &

We aeonowledge receipt of NEFT instructionls}. Reference no. /

Brench/ sTfB1 : Name and Signature of Bank Official / W W 4 W