Application for National Electronic Fund Transfer (NEFT)/
ZoeZb BboŠQ´>m°{ZH$ \§$S> Q´>m§g\$a (EZ B© E\$ Q>r) Ho$ {bE AmdoXZ
To,/ à{V, Date/ {XZm§H$
The Branch Manager/ emIm à~§YH$
PAN No./ n¡Z Z§.
Branch / emIm
*To be provided by ICICI Bank customer/
*Ho$db AmB© gr AmB© gr AmB© ~¢H$ Ho$ J«mhH$ àXmZ H$ao
Dear Sir /{à` _hmoX`,
Please remit through NEFT a sum of ` (Rupees In words) only
as per details given below:
H¥$n`m {ZåZm§{H$V {ddaU AZwgma EZ B© \$ Q>r Ho$ _mÜ`_ go ` (ê$n`o eãXm| _|) _mÌ ào{fV (ao{_Q>) H$a|:
Cash/ ZH$X Cheque/ MoH$ Debit my/our account/ _oam/h_mam ImVm S>o{~Q> H$a|
*In case of cash, please fill in the pay-in-slip / *ZH$Xr H$s Xem _| H¥$n`m O_m nMu (no-BZ-pñbn) ^a|
*To be filled by the Applicant in CAPITAL LETTERS / AmdoXH$ Ûmam ~‹S>o ñnï> Ajam| _| {bIm OmE
DETAILS OF APPLICANT (REMITTER)/ AmXoXH$/àofH$ H$m {ddaU
Account Number/ ImVm g§»`m:
Cheque Date/
Cheque Number/ MoH$ g§»`m: MoH$ {XZm§H$:
Remitter’s Name/ AmdoXH$/àofH$
H$m Zm_:
Address/ nVm:
Mobile/ Other Number/
_mo~mBb/AÝ` Z§~a:
DETAILS OF BENEFICIARY / {hVm{YH$mar H$m {ddaU
Beneficiary’s Name/ {hVm{YH$mar
H$m Zm_:
Account Number/ ImVm g§»`m:
Bank Name/ ~¢H$ H$m Zm_:
IFSC Code (11-digit) /
AmB© E\$ Eg gr H$moS> (11-A§H$)
Branch Address/ emIm H$m nVm:
Mention Account Number
Again/ nwZ: ImVm g§»`m {bI|:
Remarks (if any)/ {Q>ßnUr (`{X hmo):
Terms and Conditions / [Z`_ Am¡a eV]
This transfer is valid for a single transaction./ `h Q´>m§g\$a EH$b ì`dhma (Q´>m§O¡ŠeZ) Ho$ {bE hr _mÝ` h¡.
The fund transfer will be governed by the Terms and Conditions given on our website www.icicibank.com./ \§$S> Q´>m§g\$a h_mar do~gmBQ> www.icicibank.com
na {XE JE {Z`_m| d eVm] Ûmam em{gV hmoJm.
I / We authorise ICICI Bank to recover charges as may be applicable by debiting my account as mentioned above./ _¢/ h_ AmB© gr AmB© gr AmB© ~¢H$ H$mo
A{YH¥$V H$aVo h¢ {H$ dh bmJy ewëH$m| H$mo _oao Cnamoº$ ImVo _| S>o{~Q> H$aHo$ dgyb H$ao.
I / We understand that as per the RBI circular dated October 14, 2010, transfer of funds through electronic mode will be executed only on the basis
of the account number of the beneficiary provided while initiating the transaction; name will not be considered as a criteria for providing credit./
_¢ /h_ OmZVo h¡ {H$ Ama ~r AmB© n[anÌ {XZm§H$ 14 AŠQy>~a, 2010 Ho$ AZwgma, BboŠQ´>m°{ZH$ {d{Y Ho$ _mÜ`_ go \§$S²>g H$m Q´>m§g\$a Q´>m§O¡ŠeZ H$aVo g_` {XE JE Ho$db {hVm{YH$mar
H$s ImVm g§»`m Ho$ AmYma na hr hmoJm, Am¡a H«o${S>Q> XoZo Ho$ {bE Zm_ Ho$ _mnX§S> na {dMma Zht {H$`m OmEJm.
I understand that this facility is available only at select locations and banks covered under Electronic funds Transfer facility offered by RBI.
_wPo nVm h¡ {H$ `h gw{dYm Ho$db MwqZXm ñWmZm| Am¡a ~¢H$m| _| hr CnbãY h¢ Omo Ama ~r AmB© Ûmam Xr JB© BboŠQ´>°{ZH$ \§$S> Q´>m§g\$a gw{dYm Ho$ A§VJ©V em{_b h¢.
Transfer of an amount up to ` 49,999 in cash permissible using this facility./ `h gw{dYm à`moJ H$aHo$ ` 49,999 VH$ H$s am[e ZH$X Q´>m§ñ\$a H$a gH$Vo h¢.
Photo ID proof to be given by non customer for cash payment above ` 5,000 / ` 5,000 go A{YH$ Ho$ ^wJVmZ Ho$ {bE J¡a-J«mhH$m| H$mo \$moQ>mo nhMmZ-nÌ XoZm hmoJm.
Customer Signature (s) J«mhH$ Ho$ hñVmja
Signature/ hñVmja Signature/ hñVmja Signature/ hñVmja
Name / Zm_ Name / Zm_ Name / Zm_
*(Primary Applicant / àmW{_H$ AmdoXH$) *(Joint Applicant 1/ g§`wŠV AmdoXH$ 1) *(Joint Applicant 2/ g§`wŠV AmdoXH$ 2)
Customer Acknowledgement for NEFT transaction/ EZB©E\$Q>r boZXoZ Ho$ {bE J«mhH$ agrX
Date/ {XZm§H$
Customer name / J«mhH$ H$m Zm_:
Mode of payment / ^wJVmZ H$m àH$ma:
Beneficiary name / bm^mWu H$m Zm_:
Beneficiary account number / bm^mWu H$m ImVm Z§~a:
Beneficiary bank name / bm^mWu Ho$ ~¢H$ H$m Zm_:
Transaction Reference number / g§X^© g§»`m: Amount / aH$_: Bank Seal /
~¢H$ H$s _wha
Name and signature of Bank official / ~¢H$ A{YH$mar H$m Zm_ Am¡a hñVmja:
