Cii'FIC": 'OF THE FA&CAO/CONIS.E.
RAILWAY/G1UIDEN REACHiKOLKATA
MANDATE FORM
VENDOR/CONTRACTO;:·~/E:MPLOYEE FOR EFTIECSIRTGS/f.i"EFT PAYMEN1:
l)N.~~: _
2)ADDRESS: ~-------_---- _
3) PHONENO: _______ MOBILE: FAX No: _
.J) PAN No: EJv1AIL: ~ _
5)BANKNAME: _
6) BRANCH NAlVJE: -----------------------------------------1ELEPHONE NO-------------
7)BRANCH ADDRESS: ~--------------
8) BA..l\JK WCR CODE (9 DIGIT): B.\NK'S IFS CODE:-------------
9) BANK ACCOUNT NO_ : _
ro ACCOtJNT T'{PE: SAVTNGS/CUR.RENT/CASH CF£:;)IT: _
DEcL~~nONBY THE PARTY:
, hereby, declare that the particulars given above are correct and complete. !f the transaction is delayed
or not effected at all for reasons of incomplete or incorrect information the User l::stittrtion, i.e..
F,lI.&CAO/COi\l/S.E.RLY/GRC will not be held responsible. I have understood the scheme 2:10 agf:o] to discharge
the responsibility for which ; am !iable as a participant under the scheme. I declare that in absence of
acknow- --lgement regarding the above payment which has been credited to my Bank Account, no further
pavme-: ~_-J :'8 made by theFA&CAO/CON/GRC.
Date: Signature of the Suppiier/Party/Employee
One cancelled cneque/ photo copy of the cheque duly carrying lFS Code Is to b" enclosed.
Certified that the particur-rs furnished above are correct as per our records.
Bank's seat Signature of the authorized (·fficial of the Bark
