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Customer Request Form

The customer request form allows customers of Axis Bank to [1] change their mailing address, contact details, or account information; [2] request services like new debit cards, cheque books, or account statements; and [3] provide updated KYC (Know Your Customer) details. The form requires customers to provide their name, account and customer ID numbers, and details of the specific requests. Bank officials then note the date the request was received and acted upon.

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5K views

Customer Request Form

The customer request form allows customers of Axis Bank to [1] change their mailing address, contact details, or account information; [2] request services like new debit cards, cheque books, or account statements; and [3] provide updated KYC (Know Your Customer) details. The form requires customers to provide their name, account and customer ID numbers, and details of the specific requests. Bank officials then note the date the request was received and acted upon.

Uploaded by

stisspl09
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CUSTOMER REQUEST FORM

The Branch Head


Axis Bank Ltd.
______________ Branch.

Date of Request:

Customer Name: Mr.  Mrs.  Ms.  __________________________________________

Account Number: _____________________________ Customer ID: _______________


Please tick the appropriate box:
1. CHANGE OF MAILING ADDRESS (In case of joint holders, each holder needs to
fill a separate form)
New mailing address (with proof of address*) _____________________________________
__________________________________________________________________________
City_______________ Pin Code 
Please also make the above change in address for the following accounts held by myself.
Credit Card Credit Card Number 
Loan Account Loan Account Number _________________
2. CHANGE OF OTHER CONTACT DETAILS
Change of mobile number.
New mobile number : 
Change of telephone number.
New telephone number : 
Change of email ID:
New email ID : __________________________
3. ACCOUNT OPENING RELATED QUERIES
Cheque Book not received.
Debit card not received.
Debit Card Pin number not received.
Fixed Deposit Receipt (FDR) not received. Date of form submission: _________
4. DEBIT CARD (Please debit the charges to my A/c., if any)
Debit Card hotlisting. Debit Card Number 
Reactivation of Card Number 
Reason for not operating ____________________________________________________
Debit Card duplicate Pin issue.
5. DUPLICATE STATEMENT (Please debit the charges to my A/c., if any)
Statement required from date ________ to _________.
6. E-STATEMENT REGISTRATION (Signature of primary holder is required)
Account Number . Email ID __________________________________
7. NEW CHEQUE BOOK REQUEST (Please debit the charges to my A/c., if any)
Number of Cheque Leaves required _______.
---------------------------------------------------------------------------------------------------------------------
8. INTERNET BANKING (iConnect)
Pin not received.
User ID not enabled.
Duplicate Pin issue.
9. PASS BOOK (Please issue)
10. STOP PAYMENT REQUEST (Please debit the charges to my A/c., if any)
Number of cheques _____ Cheque Number(s)_______________________
Date of Cheque ___________ Amount _____________________
Payee’s Name ________________________________
Reason for stop payment ______________________________________________________
11. SIGNATURE VERIFICATION (Please debit charges to my A/c.)
13. REVERSAL OF CHARGES
Date of debit ____________ Amount of debit ___________________________
I undertake to keep henceforth an Average Quarterly Balance of Rs.____________________
14. ACCOUNT ACTIVATION
Please activate my Account Number 
Reason for not operating account _______________________________________________
15. ANY OTHER
Please specify here___________________________________________________________

Know Your Customer (KYC) Details:


*Document for proof of address __________________________________________________
Document Identification Number____________ Issuing Authority________________________
Place of issue__________________________________________________________________

Information on other products and offerings:


From time to time AXIS Bank communicates various new products/special features of existing
products/promotional offers which are of significant benefit to its customers. Please help us to
serve you better by giving your consent to be informed about such benefits.
Your consent : Y  N 

Date: ___________ _________________


Customer’s Signature

FOR OFFICE USE

Customer request acted upon on ___________ (Date) / forwarded to ___________ (Branch)


Name of Branch Official : _________________________
Employee Number : __________ (Signature of Branch Official)

ACKNOWLEDGEMENT TO CUSTOMER

We acknowledge receipt of ‘Customer Request Form’ from ______________________(customer


name) on ___________(date) for ___________________________________________________
________________________________________________________________________
Name of Branch Official: ___________________
Employee Number : ___________ (Signature of Branch Official)

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