MANDATE CUM SIP REGISTRATION FORM Application No.

[For investment through NACH]

FOLIO BASED MANDATE

Folio No.

Declaration: I/We hereby declare that the particulars given on this mandate are correct and complete and express my willingness and authorize to make payments referred above through participants in NACH/SI/any other mode as may be
preferred by the AMC from time to time. I/We hereby confirm adherence to the terms of this facility offered by ICICI Prudential Asset Management Company Limited (the AMC) as specified in Terms & Conditions under Registration of OTM/PAN
Based Mandate Facility and amended from time to time and of NACH (Debits). Authorization to Bank: This is to confirm that the declaration has been carefully read, understood & made by me/us. I am authorizing the user entity/corpo-
rate to debit my account. I/We have understood that I/we authorized to cancel/amend this mandate by appropriately communicating/amendment to the User entity/corporate or the or the bank where I have authorized the debit.
This is to inform that I/we have registered for this facility and that my/our investment in ICICI Prudential Mutual Fund shall be made from my/our above mentioned bank account with your Bank and to debit my/our account for any charges towards
mandate verification, registration, transactions, transactions, returns, etc, as applicable.

SIP REGISTRATION FORM Application No.

Investor must read Key Scheme Features and Instructions before completing this form. All sections to be completed in ENGLISH in BLACK/BLUE INK and BLOCK LETTERS.
BROKER CODE (ARN CODE)/ SUB-BROKER ARN CODE SUB-BROKER CODE Employee Unique
RIA CODE# (As allotted by ARN holder) Identification No. (EUIN)
#By mentioning RIA code, I/We authorize you to share with the Investment Adviser the details of my/our transactions in the scheme(s) of ICICI Prudential Mutual Fund.
TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY: In case the purchase/subscription amount Rs 10,000/- or more and your Distributor has opted to receive transactions charges,
the same are deductible as applicable from the purchase/subscription amount and paid the distributor. Units will be issued against the balance amount invested. Upfront commission shall be paid directly by the investor to
the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered by the distributor.
Declaration for “execution-only” transaction (only where EUIN box is left blank) - I/We hereby confirm that the EUIN box has been intentionally left blank by me/ us as this is an “execu-
tion-only” transaction without any interaction or advice by the employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if
any, provided by the employee/relationship manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction.
SIGNATURE OF SOLE / FIRST APPLICANT SIGNATURE OF SECOND APPLICANT SIGNATURE OF THIRD APPLICANT

The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the contents of the Scheme Information Document of the following Scheme and the terms and conditions of the SIP Enrolment.

FOLIO NO. Registration via Existing OTM [Please tick (3)]

Sole/First Applicant’s Name: Mr. /Ms. / M/s
FIRST MIDDLE LAST

Scheme: ICICI PRUDENTIAL _____________________________________________________ PLAN: ______________________________ SIP TOP UP (Optional)

(Tick to avail this facility)
OPTION:_________________ SUB-OPTION:_________________ DIVIDEND FREQUENCY:____________ AEP FREQUENCY______________
Please refer instructions and Key Scheme Features for options, sub-options and other facilities available under each scheme of the Fund. Percentage: 10% 15% 20%

other__________ (multiples of 5% only)

Each SIP Amount: Rs. In words: ____________________________________________________
TOP UP Amount: Rs._________________
SIP Frequency: Monthly Quarterly* (Default is Monthly) *In case of Quarterly SIP, only Yearly frequency is available under SIP TOP UP. * TOP UP amount in multiples of Rs.500 only.
Frequency: Half Yearly Yearly
SIP D D SIP Start M M Y Y Y Y SIP End M M Y Y Y Y SIP TOP UP CAP Amount:
Date: Month / Year Month / Year
Rs.____________________________ OR
EXISTING OTM / FIRST INSTALLMENT BANK DETAILS: Month-Year#:
Cheque/DD No.__________________ Cheque/DD Amount Rs. __________________________ A/c No. ______________________________ M M Y Y Y Y
Bank Name: _____________________________________________________________________________________________________ #
Investor has to choose only one option – either CAP
Amount or CAP Month-Year
DEMAT ACCOUNT STATEMENT DETAILS (OPTIONAL – PLEASE REFER INSTRUCTION NO. 19)
NSDL: Depository Participant (DP) ID (NSDL only) Beneficiary Account Number (NSDL only) CDSL: Depository Participant (DP) ID (CDSL only)

YOUR CONFIRMATION/DECLARATION: I/We hereby declare that I/we do not have any existing Micro SIPs which together with the current application will result in a total investments
exceeding Rs.50, 000 in a year as described in the Instruction No.IV(d) of the common application form. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any
other mode), payable to him for the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us. The AMC would not be liable for any delay
in crediting the scheme collection accounts by the Service Providers which may result in a delay in application of NAV.
Signature(s) as per ICICI Prudential Mutual Fund Records (Mandatory)
Sole/First

Holder
Holder

Holder
2nd

3rd

ACKNOWLEDGEMENT SLIP (To be filled in by the investor) Folio No./ Application No.
Name of the Investor:____________________________________________________________________________________________________
Acknowledgement Stamp
Scheme Name:___________________________________ Option: _____________________ SIP Amount Rs.___________________ SIP Frequency: Monthly Quarterly

SIP TOP UP Amt. Rs.______________________ TOP UP CAP: Amt:Rs.________________________ OR Month-Year: M M Y Y Y Y