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Service Request No.: I I
1
0 ICICI Bank Customer Requests Form
Date:I 1\ I 91 el ~I 'l.lo l'l'..IS'·
;
Customer Detail (To be filled in by the customer. Fields marked with #are mandatory.)
CR e
'.
#Customer's Name (as in Bank Ale) tn ~ N'J El. [Iv 1" rz ~ ) 6-)
:
ATM/0EBIT Card No:. I I I I I I I I I I I I I I I I I #Account No.:lo l'.3 I) I, Iols-1 ol ol'3 I~ Isl, I '
#Mobile No./ ~lg 17111'2-17171 $"'ISi ,I Tel No.:I I I I I I I I I I I
E-mail ID: ~l.l~l"Tf). J!."NJX'g. e_g_1'$l:.~
nk.com)
(Please tick the appropriate boxes. Charges will apply for fields marked with•. For further details please visit our websitewww.iciciba
ATM/DEBIT CARDS TDS
□ *De-hotlist (unblock ATM/Debit Card)
□ ATM/Debit Card not received □ TDS Certificate request for the FY I 1(1 (IYH (1 ✓ 1Y1 I
□ Card expired, new card not received □ Interest Certificate request for the FY I flflYIYHvlYI flvl
□ Card swallowed by ICICI ATM on 1> I I I r., I ~, I , IyI , I· I
□ Card swallowed by NON ICICI ATM onl 1, O I I ._,, ,, I I•. I yI yI □ TDS Certificate not received for FY
I I ( I • I yH I'{ I , I I
ATM RESPCODE: Cust. ID
□ D Upgrade my Debit Card Bra,·
□ 15G/15H Form submitted at
D *Reissue Card Reason: □ Lost D Damaged
D *Jssue a new Debit Card
Name to be printed on the card: on I ' I c I '·' I MI •I I I Ibut tax deducted
I
NRE/NRO Debit Cards:
D Silver D Platinum D World Debit Card INTERNET BANKING
Preferred delivery for ATM/Debit Card:
D Mailing address (please confirm if address is updated) □ *To enable User ID
D Branch □ *Request for Internet User ID and Password
AT~/DebitCharg es oflNR 375/- (plus service tax) will be □ *Request for Login Password
applicablefor deliveries outside India.
Login □
·- CHEQUE BOOK
□ Password not received
N □ Unable to view linked accounts
0
-
0
O>
:
□ New Cheque book request:
No of Cheque Book/s requested
Linked Account No.: I I I I I I I I I I I I I
Preferred delivery: □ *Account Type: D Bank D Credit Card D Demat D Loan
D Branch D Mailing address (please confirm if the address
is updated) □ Site problem: User ID
d cheque book (5 Leaves) Error message:
□ *Non-personalise
Purpose of request Error page: Error Date:! o I o I MI MI Iv I y y I Y I
(please submit ID proof)
□ Transaction notfunctioning in internet banking:
□ Cheque book not received, request placed through: D Bill Payment D Fund Transfer □ Miscellaneous
D Requisition slip D Phone banking D Internet banking
D ATM/ATM dropbox on I u I I \ I I I , I ·I, I User ID Transaction
D Branch at (Branch name) I , I I I ,I I, I I I
Date: I
STATEMENT Credit Account No.: I I I I I I I I I I I I I
□ Statement required:Froml I I ·I ·I I· I I !Toi H+,l·l·l·I I Amount Biller's name
Purpose of request
(Charges applicable as per period of statement)
□ Passbook request
•Request for Duplicate Passbook D
□ Statement not received for the period :
From[ I -I I I , I I ' I ITo I I I I ~-I (I · I I, I
I t r,, y
Declarations for NRI Customers - ATM/Debit cards/chequebo ok Reissuance
to
• Silver debit card shall be issued to Regular NRI, Platinum Debit Card shall be issued to NRI PRO Accounts and Word debit Card shall be issued
NRI Pr.emia accounts. Annual fees shall be applicable if debit card is not issued as per Product variant, refer website for applicable charges
• 1agree to update my email ID/contact numbers mentioned above in the bank's records for any further corre~pondence
• IJWe_h~~eby agree that we have read and understood the terms and conditions and instructions available at icicibank.com /nri or/and Customer
requisition form from time to time that apply to and regulate the operation of the products and services and facilities mentioned herein above
nd
• I/We u erstand that any correspondence regarding this service request shai°I be sent to email ID and mobile number registered with the bar!<
#Signature of th e customer (as per Bank records)·
________
----=.:=.------------------------------------------------. ----------------------------------------------------------------------------------------------
ACKNOWLEDG MENT SLIP (TO BE FILLED IN BY THE BANK STAFF)
I I I I I IDate: I I I I I Iv I v IYI
Received from
I Nature of request :
Ale No:! I I I I I IService request No
L r:i M M Y
ICICI BANK (B
~ ranch Name and Stamp) :
ICICURSPPG/4 0I07171UABICRF
Signature Of Bank Official
RETURN CHEQUE OTHERS
□ Payee details required: Amount (int) □ Others (please specify
- I
Cheque No. Drawn on
Date of transaction: I o I o I I I v I r Iv I I
M M STANDING INSTRUCTION
-
□ Returned cheque not received □ *Amount (in Rs.) Frequency
Cheque No. Amount: I IuI,., I I I I , I jTo I I I,. I I I I I J
From r 1
Deposited at: Drawn on Debit A/C No.IIIIIIIIIIIII
I
Date of deposit: u j o j r, I M j Y I I , I,· I Name
0 Credit A/C No. I I I I I I I I I
FIXED DEPOSITS/RECURRING DEPOSITS
Name
IIII
□ FD No.: IIIIIIIIIIIII □ Standing instruction not executed.
□ Link FD to I I I ~I, I I I
operative A/c No: I I I I I I I I I I I I I Instruction date! P ri r r jat Branch
(If FDR was issued, please return it)
TRANSACTION DISPUTE
□ FD Receipt/MOD not received - -
□ Erroneous Credit/Debit in A/c:
□ Incorrect tenure Required tenure
Cheque No.
□ Interest rate mismatch
□ Non receipt of interest Pay Order for interest for quarter/ Date of transaction: i I I,. I ,I I I I I
I y
month Amount Drawn on
□ Interest not credited for the Quarter/Month of
□ Charges debited to account: Amount
□ Senior citizen interest not received
Date of transaction: I 1' I l I~-• I I I I •I I
1•1 Y
FUNDS NOT CREDITED TO THE ACCOUNT □ 0 ATM D Cash not dispensed from ATM
D Insufficient cash dispensed from ATM
□ Amount credited:
Amount deposited:
Date of transaction: I I I~I I I( I •I•I
[J
1 r.1 y
□ Cash deposit_ed at Branch onj o o
but not credited to A/C
l IMI I"I( I YI" I
r.1
ATM No.:
ATM RESPCODE:
Transaction No.:
Amount:
□ Salary not credited : Amount disputed: (Attach copy of transaction slip)
Company Name: CHANGES/ADDITIONS/DELETIONS
N Amount:
0
□ Address change not done: Application given on:
□ Cheque Deposited: □ ATM O Dropbox
ATM No. Transaction No.
I I I I l I •I I at
j u O 111 M Y Branch
Nomination D Not registered D Not deleted D
Cheque No. Date! u I I~" I I"I I I I
O M Y Y i Instruction date! I ' I ·I r., I I · I "I · Iat
1 y Branch
Amount: Drawn on
□ Mode of operation incorrectly updated:
□ Account opened, funds not credited Self □ Either or Survivor □ Jointly □
Cheque No. Datej ') I I '- I ~ I ' I I ' I., I
J Y
Other, please specify
□ Joint applicant's name not included
□ SB Interest not credited for the month of Joint applicant's name
ACCOUNT NOT OPENED □ Addition/Deletion of Joint A/C holder(s) not done instruction
□ Form submitted on I c, j 1., j I MI {I I {I I y f
given on j o I I I I I I I . Iat Branch
Branch/Sales Team Date :J o I )I, I I (I , I I I ti Y
For GUNJ A ENTERPRISES
For GUNJK ._.~. -· ,.
_1,~l~ /Jr
Partner
#Signature of the customer (as per Bank records) Pa tn1
Declaration by Branch Official - I confirm
D Customer called on registered mobile no- - - - - - - - and reason for deliverable request confirmed
Em pIoyee ID:
Signature of Bank Official:
-----------
Date of call:
Time of call:
-
_ 1 ,
0
Remarks:
ICICURSPPG/4.0/0717/UAB/CRF Page 2 ol 2
