Get Mandate Form Format

Appendix VIII FORM NO. E-5 LAN No. Only for official use ELECTRONIC CLEARING SERVICE DEBIT CLEARING MANDATE FORM Please fill-in the information in Capital letters The Manager Copy to the User Company Bank Name Branch Name Address Telephone No. Name ---------------------------Address -----------------------------------------------------------Telephone No.------------------ I Account Holder Name as per Bank records hereby authorize you to debit my account for making payment to ICICI Bank Limited through ECS Debit clearing as per the details given as under. A. 9-DIGIT CODE NUMBER OF THE BANK BRANCH Appearing on the MICR cheque issued by the bank B. ACCOUNT TYPE Savings 10 / 31 / Current 11 / 29 / Cash Credit 13 / NRE / NRO C. LEDGER NO / LEDGER FOLIO NO. D. ACCOUNT NUMBER As per Bank Records Name of the Scheme Date of effect Periodicity M/BiM/Qly/etc* E* Amount of installment/ Amt Number of installments/ Valid of bill with upper limit up to in case of utility bills I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information I would not hold the user institution responsible. I have read the option invitation letter and agree to discharge the responsibility expected of me as a participant under the scheme. Signature of the Customer Account Holder/s - In case of Joint A/c holders Signature is required of all A/c holders. Any one Signature required In case of Either / Survior A/c* Date Certified that the particulars furnished above are correct as per our records. Bank s Stamp --------------------------------------------Signature of the Authorized official from the Bank Note - Mandate to be obtained in 3 copies Original for Bank One for User Co. and other for customer For ICICI BANK LTD Use only To be filled by Business Team Name of the Applicant Name of the co-applicant Application Number FreshSwap In case of Swap previous mode Mandatory Fields. A. 9-DIGIT CODE NUMBER OF THE BANK BRANCH Appearing on the MICR cheque issued by the bank B. ACCOUNT TYPE Savings 10 / 31 / Current 11 / 29 / Cash Credit 13 / NRE / NRO C. LEDGER NO / LEDGER FOLIO NO. D. ACCOUNT NUMBER As per Bank Records Name of the Scheme Date of effect Periodicity M/BiM/Qly/etc* E* Amount of installment/ Amt Number of installments/ Valid of bill with upper limit up to in case of utility bills I hereby declare that the particulars given above are correct and complete. LEDGER NO / LEDGER FOLIO NO. D. ACCOUNT NUMBER As per Bank Records Name of the Scheme Date of effect Periodicity M/BiM/Qly/etc* E* Amount of installment/ Amt Number of installments/ Valid of bill with upper limit up to in case of utility bills I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information I would not hold the user institution responsible. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information I would not hold the user institution responsible. I have read the option invitation letter and agree to discharge the responsibility expected of me as a participant under the scheme.