SERVICE REQUEST FORM
Please fill the form in BLOCK LETTERS and tick the required service/s. Application Date / /
DD MM YYYY
Account Name
Account Number Customer ID
Change of Address
(In case of Joint Applicants, each applicant to fill a separate form. Proof of new residential / registered address is mandatory)
Residential / Registered Address Correspondence Address Both
Flat / Room No. Floor Block / Tower
City Pin/Zip Country
Change of Contact Details
Residence Phone
Country Code Area Code Number
Office Phone 1. 2.
Country Code Area Code Number Country Code Area Code Number
Mobile Phone 1. 2.
Country Code Number Country Code Number
Email Address
Stop Payment
Please stop payment of the following cheques and debit charges to my / our account.
Cheque No. Reason
1.
2.
For Stop Payment of Cheque in Series:
Cheque No: From To Total Number of Cheques
Reason
Duplicate Statement
Please issue duplicate statement of account & debit charges as applicable to my / our account.
Statement From: / / To / /
DD MM YYYY DD MM YYYY
Delivery Instructions: Send to mailing address by post Email to registered ID To collect from Branch
Cheque Book
Please issue Cheque book and debit charges to my / our account.
Delivery Instructions: Send to mailing address by courier / registered post* To collect from Branch
*Courier / Registered Post charges as applicable
Bank Confirmation
Please issue Bank certificates for: Address Confirmation Account Confirmation Balance Confirmation
as on / / and debit charges to my / our account.
Delivery Instructions: Send to mailing address by courier / registered post* To collect from Branch Send to auditor’s address by courier / registered post*
Address of Auditors:
Flat / Room No. Floor Block / Tower
City Pin/Zip Country
*Courier / Registered Post charges as applicable
Change of Name
I request you to please update my name in your records. I submit herewith the name change document:
Existing Name
New Name
Reason for Change in name Page no 1 of 2
Change of Signature
I hereby request you to update my new specimen signature in your records:
Existing Signature New Signature
Account Closure
I / We wish to close our above account with you. I / We confirm that I / we have destroyed the unused cheque leaves/
surrender the following cheque leaves to
I / We confirm that there are no cheques issued by me / us are unpresented till date. The Bank would not be liable for any dishonor of cheques presented
for the above accounts as the same would no longer be valid and available for operation.
Please close the account & pay proceeds after deduction of charges if any.
Cashiers Order in name of
Wire Transfer to my / our account as per details below:
Account Number CCY
Account Name
Bank Name
Swift Code Additional Information
Fixed Deposit Maturity Instructions
I / We request you to change the maturity instructions of the foWowing Fixed Deposits
Deposit Numbers
Do not Renew Renew Principal & Interest Renew Principal & Pay Interest
Payment Mode for Principal & Interest:
Credit to Account Cashiers Order Transfer to Other Bank
Account Number
Account Name
Bank Name
Swift Code Additional Information
Delivery Instructions for Cashiers Order Send to mailing address by courier / registered post* To collect from Branch
*Courier / Registered Post charges as applicable
Premature Encashment of Fixed Deposit (Premature Liquidation is not allowed on Non- Withdrawable Deposit)
I / We hereby request to premature encash the following Fixed Deposits and understand that premature encashment is subject to terms & conditions
as stated in the schedule of charges and is at the sole discretion of the bank.
Deposit Numbers and pay by
Credit to Account Cashiers Order Transfer to Other Bank
Account Number
Account Name
Bank Name
Swift Code Additional Information
Delivery Instructions for Cashiers Order Send to mailing address by courier / registered post* To collect from Branch
*Courier / Registered Post charges as applicable
I/We understand that the Bank will not be liable for any delay or failure to carry out above instructions where such delay / failure is attributable to any cause beyond the
Bank's control including any equipment malfunction or failure and under no circumstance shall the Bank be responsible to me / us for any consequential or indirect losses
arising out of or In connection with the carrying out or otherwise of my/our instruction. l/We understand that the Bank reserves the right not to process any request with
or without notice if this form is not accurately or properly completed, including, without limitation, the adding of any special instruction by me/us that is not provided, for in
the fields set out in this form. I/We have read the general terms & conditions & agree to be bound by them.
Signature Signature Signature
Name Name Name
For Bank Use Only
Account Opening Date / / Signature Verified By Charges debited ✔ Yes No Amount
DD MM YYYY
Processing Date / /
DD MM YYYY Inputter (Name & Employee Code) Authoriser (Name & Employee Code)
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