NATIONALIZED ELECTRONIC FUND TRANSFER DETAILS
Provider Information
Hospital code with FHPL(PRC): Date:
Hospital Name:
Hospital Address:
Contact Person Name and Phone No.
(Payments related):
Email Id:
Provider Bank Account Details
Name of the Bank:
Bank Account No.:
Bank A/c.Name (Payee Name):
Bank Account Type:
Bank Branch:
Bank Address:
IFSC Code:
IFSC Code IN words:
MICR No.:
PAN No.:
PAN Card Type: 1. Individual 2. Company 3. Firm 4. Trust 5. HUF 6. Others
Name on PAN Card (Deductee Name):
I / We hereby declare that - the above information provided by me / us is best to my / our knowledge and also
I / We accept the Electronic payment facility and declare that I/we is/or holder in the above mentioned bank account
and any liability arising out of this facility, directly or indirectly, now or in future, would be borne by me/us.
I/we understand that this facility is subject to a minimum amount of payment, being payable to me/us.
Authorized Signatory
Name: Bank Attestation
Designation: Bank Seal
Contact Phone No: Authorized Signatory
Hospital / Company Seal Date:
Date:
Enclosures:
1. PAN Card copy 2. Cancelled cheque original only / Bank NEFT confirmation letter
3. Service tax registration copy 4. Bank statement / Pass book copy (in case of Payee name not printed on cheque)
Note -
1. To be filled in English & block letters.
2. All the details needs to be filled / provided mandatorily, failing of which application shall be considered incomplete.
3. FHPL reserves the right to physically verifythe facts by visiting the centers.
4. All documents need to be duly signed and stamped.
