.

• :) f ,~ r '
- - "
- ---- - ·--- --
fl ICICI Blink Application for Funds Transfer through RTGS / NEFT- - . -- - -
\
(Select RTGS or NEFT as remittance type)
'311<c!l;,llqa / t m'tZllr um~ t • -
To/llf'a, (~1<el;,llqa q i ~ ~ )
The Branch Manger/~

Dear Sir/~~.
Branch/mffl
Date~: I n/ 0 / / M / " / v / Y/ Y /

Please remit through NEFT/ RTGS a sum off (Rupees in words)

only as per details give below:
(~f)
~~q;"t
0 Casll(only for NEFT)~ ( ~ t ~)* D Cheque/Wli D Debit of my/our account (only for NEFT)
•in case of cash please fill in the pay-in-slip / m / lffi~llffi!T~q;l ( ~ ~ t ~)
To be filled by the Applicant in CAPITAL LETTERS~~~ll m
0

·;-;~~~?}:·/;~~ ::.-·~~~~:·? .~,~·:: . ~- ... , ..

.: \'i>EtAILS.QF AP~LIC:ANf (REiVIITTER)~/~"iiir ~ ·- .·· •· ' . - ~. .~·.
-~
, .' '
.. ' · • " , • , - • 1 , , •• l • • l , , .. . . --
• Account Number/llffi!T tR&JT:
I I I I I I I I I I I I I
The Legal Entity Identifier (LEI) (20-digit number) :j
I I I I I I I I I I I I I I I I I I I I
Datet j I I MI MI v I I I I
Validity date of the LEI Number (Date sh_ould have a validity fo r subsequent fortnight) O O Y Y Y

• Note : The LEI mentioned on the slip must be matching with the LEI submitted and recorded by the customer with the Bank
either at the account opening stage or subsequent stages.

Applicable for all payment transactions of value f50 crore and above for NON individual customer
Cheque Date/
Cheque Number/~ .'JaR:
Remitter's Name/
I I I D I O I MI M I y Iy I y Iy I
$Ii <f;l <lltm:
~q;r';JTJJ: I I I I I I I I I I I I I I I I I I I I I I I
Address/1«1T:
I I I I I I I I I I I I I I I I I I I I I I I
Mobile/ Other Number/
I I I I I I I I I I I I I I I I I I I I I I I
~/-m: I I I I I
.;:·.> . \ .; . -... . ;:-: . .. ,, -:- . . ' ;,_ ,.·.
. ' DETAILS oi= BENEi=ltrARY / ~ 'itif'fcmvr · :• • ' .. _-.. - · - ,_ ....-(, ••• _1. . .

Beneficiary's Name/
q;r ';JTJl": I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Account Number/
q;r llffi!T 'fficllT: I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
The Legal Entity Identifier (LEI) (20-digit number) :j
I I I I I I I I I I I I I I I I I I I I
For all payment transacti.ons of value f50 crore and above for NON individual customer)

Bank Name/~*~q;r';JTJJ I I I I I I I I I I I I II I I I I I I I I I I I I I I I
IFSC Code (1 1-digit)/
&11{qq,qeal <1>16 (11 3tq;):
I I I I I I I I I I I I
B~anch Address/
mfflq;f'l@l: I I I I I I I I I I I I I II I I I I I I I I I I I II I
Confirm Account Number
Agai~ 'fl: ffl<!I ~; I I I I I I I I I I I I I II I I I I I I I I I I I I I I
Remarks (if any)/ ~ (~ ~) :

p
--
.. .. "

Cash Management Transfer/ Supplier Payment

l CASH INTE lnterestfiin;;r SUPP
/~'l¥IBR
Trade Settlement Payment/
CORT
oQTQRFllreR'lf@R LOAN Loan/1WJT TAXS Tax Payment/ q;{

DIVI Dividend~ PENS Pension Payment/ TRAD TradefciqrqR

ffi 'lj1@R
Government Payment / Salary Payment/
GOVT 'lj1@R SALA ~'lflc!R TREA Treasury .Paymen~
HEDG Hedgin~ SECU Securities / VATX Value Added Tax Payment/
~fiq;{'lf@R
Intra Company Payment/ Social Security Benefit/ WHLD With Holding/UlJ;
INTC SSBE
w 'lflclR ~~P;!T'RN

• This transfer is required for a single transaction/•1nt<1liroll~'l"'~il;fllqt 1

• The fund transfer will be governed by the terms and c,onditions given on our website www.icicibank.co~M 3flRVr~~www.icicibank.com<R~
'11{f.ltl,ilaftu1li!t3@lf<ll),n1 ·
• I/ We authorise ICICI Bank to recover charges as may be applicable by debiting my account as mentioned above/ i'I /'-(q ~,antt,,; '!F"'•tfilq
~t ~~11ra~~<Rf.l'l!~-t I
• I/ We understand that as .per the RBI circular dated October 14, 2010, transfer of funds through _electronic mode will be executed only on the basis
of the account number of the beneficiary provided while initiating the transaction; name will not be considered as a criteria for providing creditJi'I /
"'·~tflli arnl.anf 'llm 14 201ot ~ ~ ~ t - u ""~~~""1J,ft~l!l!lJl\1'5111t nt<R~~; ""1J,ft""'-1111· ~~mtfllq~t"'i'I ,il'IRl;;nqrn I
• I understand that this facility is available only at select locations and banks covered under Electronic Funds Transfer facility offered by RBI /rJ?lfif t ~'II'~
.-ft3nfim-~ ~~~~tm,it..l'<'lfur~>flt~'lt-tl
• By signing on this RTGS Payment Instruction, the Customer agrees and acknowledges that this RTGS Payment ln~truciion and the ICICI Bank RTGS Facility
is subject to the Terms and Conditions, the Notice and these terms, and requests the execution of these instructions in terms thereof/ t u ~
'fll!R~~m.~ ~ ~ • f l l i ' l l ~ ' f l l ! R ~ am'ffiif, ii; ~t am~-ira;,1,-i,,n,,~t~tfilq • • '
• Terms used but not defined herein shall have the meaning ascribed to them in the Terms and Conditions/~ffl'!Rl~O!A'lr.lh1al<1t~'ltffll;,n1Jllf!, llllR al'i
o-rf.ltl,il~~i'l~l),n 1-q 3@lf<I~, f.lqq~~i'l~t I . - -- -
• The Customer understands that the terms enumerated in this RTGS Payment Instruction are in addition to and not in derogation of the Terms and
Conditions/~ ~'J'Tl!R~~f.l'l'I.~f.ltl,il aftt'ffiif~~~~ 1 _·
• Subjecf fo ICICI Bank's right, at its soie discretion, to accept or reject ihe RTGS Payment Instructions, ICICI Bank shall endeavor to duly execute these
instructions, except when, inter alia, this RTGS Payment Instruction is incomplete 9r has been filled in wrong!'/ _or -the j~structions herein cannot be
executed under the RTGS. An acknowledgement of receipt of this RTGS Payment Instruction shall not be const~ued as binding ICICI Bank to execute
the same, other than in terms of the Terms and Conditions ~~'l_"la, ai$1\~onttil;~ ~i'lt,>ll 'J'Tl!R~ "'{U/mra
lrt)tu"R!tlll~~~~t~~~f.l;,n""m~fiilfat3@1s'J~.-l~~~"'u~<5R~Wlmm1~~'J'fc!R~.f;t~~~f.lll'!~
mifil; amlftiffl ai$1\a,mf\Ollth.tfilqw-mt\~~ I . . . ' •
.,.;.. · · ICft(~ank has not lllade any warranty and n:-i8k8s no r~pr~~entiltioil.ab~ut the q~ality, 'ti~llff~ Qr availability ot,t;i.8 ICI.CI e·ank RTGS Facilityt~ait
-- -~~P~Tffill. ~'IT~t~i'l~~,>utit'ltf-.mr1 ·
• ICI_
GI Ba_nk shall have no obligations to any person including any beneficiary (or any person claiming under or thf!iu'gli such beneficiary) oth!lr tha_ n the
Custoinerfor the execution of this RTGS Payment lnstruciion/~a,mf\,anfh.,i;'\{ll ~ ~ ~ t ~.tfllq~~·ommfllitll,ftffl'lllll(lll~ .mmfft~~
<5R'l@)fllitll,ft~il;filq~~'ltfffllll I • t ,.. '
The .Customer is hereby notified that there is a risk of non - payment to the beneficiary on tne day of the transaction . The same may be for any reason
whatsoever, including a holiday at the beneficiary's branch. lCICI Bank or R.BI or any oth_ er participant in NEFT(RTGs'siiall not be liable, in any manner
whatsoever, to the Customer for any such delay /~~~~=i~~-il,'lt~~li,) 'l'RIR'"~""~'· '!l~.\/l~A~m.nt,farnilolNllff;ft=i'llfl\,ft"'1fiffl
t al$tlan(tftanft,,;'IT arnlont'IT~, ~llfir,n,ftM,ft~u~tr.1,p;11wi;tllfil~'ltf~ , · · ·
For NEFT.: Transfer of an amount upto U9,999/- in ·cash is permissible ~sing this facility. KYC to be provided by non customer. Cheque is mandatory
for remittance above U00,000/-. l1lf~,i;Ja,i,i\,Jffl?49,999/ -R$\~~il;~$\~I 1fit~W(TKYClll\R~~~II ?100,000/-U-ai<RtR'l'l!tfilqq~t 1
· •. 1 r, 1, ;, l ) :,t ,_, , , _, .1) " ,. , •. (J ~ ,.

I~----S-ig_n_a_tu_r_e_/'?Ri_<1_r~
- ---~I ._I_____s_ig_n_a_t_u_re_,~_______.,II -----S-ig_1_1a_t_u_re_M@T
__~_,---~I
Narne/"lfll' Narne/:;:{lll ,_ . Name/~
*(Primary Applicant)/~ .~qbint Applicant~~ 2)

1. Sign and Employee ID (Maker):

2. Sign and Employee ID (Checker):

3. UTA / PIO Number:

4. Transaction ID:

,I
Customer name/
~<lil'IIJI':
Mode of payment/
D~ e:I O O M Y Y Y Y I I I MI I I I I
Beneficiary name /
llT'l1"11&1;n,i: 'l]'@A<lilWIITT::
Beneficiary account
\
Beneficiary bank name /
~t~'!lij'IPJ: numberMN!'ff ~111@1~: __________________
Transaction reference

8
number~tro;qi: Amount/~ : _ _ _ _ _ _ _ _ _ _ _ _ _ __

Name and signature of Bank official/ ti!; ?lij 'l1JI' aftl