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Bit the amount along with your charges to my/our account with you. We agree to abide by the terms and conditions given overleaf. DETAILS OF THE APPLICANT DETAILS OF THE BENEFICIARY NAME NAME ACCOUNT TYPE CITY ACCOUNT NUMBER BRANCH NAME AND ADDRESS CUSTOMER ID: IFSC CODE TELEPHONE NO ACCOUNT TYPE AMOUNT OF REMITTANCE Rs. ACCOUNT NUMBER BANK CHARGES Rs. TOTAL AMOUNT PAN NO Rs. CUSTOMER ID APPLICANT S SIGNATURE TELEPHONE / FAX NO.

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