Professional Documents
Culture Documents
Branch:
Date : 0 4 0 5 2 0 1 8
I / We hereby apply for Pay Direct Card / Meal Card with your bank. DD MM YYYY
PERSONAL DETAILS
*New Applicant: G O P I C H A N D S A I S R I N U C H I P P A D A
First Name Middle Name Last Name
*Gross Annual Income: Nil Upto 1 Lac > 1 Lac -10 Lacs > 10 Lacs
COMMUNICATION ADDRESS
* Flat No./Society Name: H N O 3 8 6 G E E T H A B H A V A N
* Road No./Name: 4 t h C R O S S T U L S I T H E A T R E R O A D
* Nearest Landmark: M A R T H A L L I
* City: B A N G A L O R E
* State: K A R N A T A K A *PIN : 5 6 0 0 3 7
*Country: I N D I A
*Tel.No.: STD Code (R) (O) Mobile 9 7 3 9 8 8 4 4 6 6
E-mail ID: g o p i c h a n d . 1 8 9 @ g m a i l . c o m
PERMANENT ADDRESS
*Flat No./Society Name: H N O 4 - 7 A
*Road No./Name: V A S A N T H N A G A R
*Nearest Landmark: D U B A C H E R L A
*City: N A L L A J E R L A W E S T G O D A V A R I D T .
*State : A N D H R A P R A D E S H *PIN : 5 3 4 1 1 2
*Country : I N D I A
*Tel.No.: STD Code (R) (O) Mobile 9 7 3 9 8 8 4 4 6 6
(Verified true copy of any of the following valid documents, to serve as Address and Identity proof, duly verified with the originals by a bank official):
PAN/
* GIR No. Of First Applicant : B C S P C 9 1 0 0 Q * (Copy of Pancard Mandatory)
OR
FROM 60 / 61 (TO BE FILED BY THOSE WHO DO NOT HAVE EITHER PAN OR GIR)
do hereby declare that what is stated is true to the best of my knowledge and belief. Verified at this the day of 200
*Office Address:
* City : B A N G A L O R E
* State : K A R N A T A K A * PIN Code:
* Country: I N D I A
* STD code: Tel.:1 Tel.:2 Extn.No.:
Address & Signature verified as per the company records
Name of Authorised Signatory:
Company Official’s
Signature Verified Date:
by the Bank Officer DD MM YYYY
Signature with Seal (AM & Above/SE/BDE)
If yes, please specify the current relationship with ICICI Bank: Bank Account Loan Account Credit/ Debit/ Prepaid Card
Others, please specify
Please provide details of the current relationship
CARD CHARGES
Annual Fee of Rs. 150/- shall be debited from the Card Upload amount towards Maintenance of Card Account. (For details please refer Terms and Conditions on our
website www.icicibank.com)
DECLARATION
I have understood and hereby agree to the Terms and Conditions as applicable to my Card set forth on the 9. I hereby authorize ICICI Bank Ltd. / its group companies to exchange share or part with all the information
website www.icicibank.com. I understand that access to any changes/update in Terms and Conditions data or documents relating to my Application to other ICICI group companies/ Bank/ Financial Instruction/
applicable to this relationship would be available on the website only. I do hereby declare that information Credit bureaus / Agencies Statutory Bodies such other persons as ICICI Bank Ltd./ its group companies may
furnished in this form is true to the best of my knowledge and belief. deem necessary or appropriated as may be required for use or processing of the said information/data by
such person or furnishing of the processed information/data/products thereof to other banks/financial
I declare, confirm, agree: institutions / credit provider / users registered with such persons and shall not hold ICICI Bank Ltd./its group
companies liable for use of this information.
1. That all the particulars and information given in this Application Form (and all documents referred or 10. I agree and understand that I have to complete further Application Forms for specific liability products
provided therewith) are true, correct, complete and up-to-date in all respects and I have not withheld any services from ICICI Bank Ltd./ its group companies as prescribed from time to time and that such further
information. I understand that certain particulars given by me are required by the operational guidelines Application shall be regarded as an integral part of this Application and vice versa and that unless otherwise
governing banking companies. I agree and undertake to provide and further information that ICICI Bank disclosed in such further forms are prescribed the particulars and information set forth herein as well as the
Ltd./its group companies may require. documents referred or provide herewith are true, correct, complete and up-to-date in all respect. I agree
2. That I have no insolvency proceedings initiated against me nor have I ever been adjudicated insolvent. and understand that such further Application will require incorporation of the Application form number,
3. That I have read the Application Form and brochures and am/are aware of all the terms/conditions of and/or such details as ICICI Bank may prescribe, to facilitate data management.
availing finance or service or products from ICICI Bank and its group companies. 11. I authorise ICICI Bank Ltd. to issue an ICICI Bank Pay Direct Card / Meal Card to me. I acknowledge that the
4. I agree and understand that ICICI Bank Limited / group companies reserve the right to reject any Application issue and usage of the Pay Direct Card / Meal Card is governed by the Terms and Conditions as in force
Form without providing any reason. I agree and understand that ICICI Bank Ltd. / its group companies from time to time and agree to be bound by the same. I accept that the Terms and Condition of Pay Direct
reserve the right to retain the Application Forms, and the documents provide therewith, including Card / Meal Card are liable to be amended by ICICI Bank Ltd. from time to time. I further unconditionally and
photographs and will not return the same to me. irrevocably authorise ICICI Bank Ltd. to debit my Card Account annually with an amount equivalent to the
5. I have also read and understood Terms and Conditions under which the scheme is offered to my fee and charges for use of the card. I hereby confirm that this account will be operated singly.
organisation and its employees. 12. I shall at all times comply with applicable laws and regulations while using this Card.
6. I agree that my employer has full right to reverse an instruction given by them for any amount within a 13. I understand that it shall be my responsibility to keep the Card, its PIN and password/s protected and
period of three working days and I will not dispute or hold the bank responsible for any such debits on the concealed at all times. I shall not hold ICICI Bank liable for any loss / damage / harm resulting from a failure
Card. to do so.
7. I understand that it is my responsibility to inform ICICI Bank immediately on termination of my employment 14. I hereby agree to keep ICICI Bank fully indemnified against any loss / damage / harm that may be caused to
with my current employer whereupon I will cease to enjoy any or all benefits under this scheme, and to ICICI Bank as a result of breach of any declarations, breach of any terms and conditions or any unauthorized
inform ICICI Bank & its group companies regarding change in my residence / employment and to provide / unlawful use of the Card.
any further information that ICICI Bank & its group companies may require from time to time. 15. The Applicant/s has/ have no objection to ICICI Bank Limited, its group companies, agents/ representatives
8. I authorize ICICI Bank and/ or its associates to verify, make enquiries with respect to any information or to provide me/us information on various products, offers and services provided by ICICI Bank Limited/its
otherwise at my office/ residence or to contact me or any other source to obtain or provide any information group companies through any mode (including without limitation through telephone calls/ SMSs/ emails)
that ICICI Bank may consider necessary in respect of or in relation to information in this Application/ further and authorise ICICI Bank Limited, its group companies, agents/representatives for the above purpose.
Application Forms including but not limited to confirming membership requirements or maintaining my (Please tick Yes or No, as acceptable to the Applicant/s) : Y or N
account in good standing.
Applicant's Photo
Date: 04 05 2 0 1 8
DD MM YYYY
*Name and Designation of the Bank Official/ SE/ BDE authorising the Application form:
Date: 04 05 2018 Employee No.: 600067 Signature of Bank Official / SE / BDE and
Branch stamp with Branch Code
DD MM YYYY