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The document is an all-in-one customer request form for banking services, allowing customers to request various services such as cheque books, account statements, and account closures. It includes sections for customer identification, service requests, and a declaration of accuracy. Additionally, there is an office use section for verification and processing of the requests made by the customer.

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31 views

null

The document is an all-in-one customer request form for banking services, allowing customers to request various services such as cheque books, account statements, and account closures. It includes sections for customer identification, service requests, and a declaration of accuracy. Additionally, there is an office use section for verification and processing of the requests made by the customer.

Uploaded by

fpcwr8xk49
Copyright
© © All Rights Reserved
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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ALL-IN-ONE CUSTOMER REQUEST FORM

__________________________________________________________________________

Branch……………………………………………………. Br Code ………………………………………

Account No  Customer ID 


Account type:  SB  CD  Overdrafts  CC Mode of Operation:  Self  E or S  Joint  F or S  Anyone

Name of the customer ………………………………………………………………………………………………..

Mobile Number …………………………………………………………………………………………………………….

Dear Sir/Madam

I/We request your good office to provide me/us with the following service/s in the above mentioned account: (Please tick mark the requests
which is/are to be processed)

 Number of cheque books ………………………….. (Each cheque book will have 10/25/50/100 leaves)

Point of Delivery  Permanent Address  Communication Address  Branch.

 Stop Payment: Cheque no from……………………………….. to …………………………………, no: of Leaves…………………………….

Payee name…………………………………………………………………………………………………………………………………………………………...

Date of Cheque: ……………………………………………………

Amount of Cheque: ……………………………………………… In figures: Rupees ……………………………………………........................

Reason: …………………………………………………………………………………………………………………………………………………………………..

 Account Statement for the period from …………………………………………………..to …………………………………………………………

 Issue Passbook  New  Duplicate.

 SMS alerts: De-activate SMS services on my/our mobile number…………………………………………………………………………….

 Mirror Plus: Branch token/ MPIN reset for the mobile number……………………………………………………………………………….

 ATM CARD:  Closure  Re-pin  Block my/our ATM card …………………………………………………………………..... (mention card number).

 Account Closure: Items submitted for a/c closure:  Passbook  Debit card  Cheque Book.

Reason for closure: ………………………………………………………………………………………………………………………………………………………………………………….Please


do the needful to credit the closure proceeds to my A/c No:………………………………………………………………, IFSC…………………………………………., Name of
bank…………………………………………………………………………. Also cancel/destroy all my un-used cheque leaves as on ……………………………….

Declaration by Customer

I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. I/We have read, understood the terms & conditions of various
products and services. I/We accept and agree to be bounded by the Terms & conditions as displayed in your website. I/We agree that the Bank may debit service charges plus taxes from
my account wherever applicable and I/We hereby authorize the bank to debit the applicable charges for the same from my account number_________________________________ .I
/we hereby understand that the bank will not be in a position to process the requests incomplete in any aspect. . I/We hereby undertake that periodic KYC updations will be carried out
as per the policy.

Place: Date: Signature:

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Office Use: Documents received Self Certified True Copy Notary Risk Category High Medium Low

I hereby confirm that the Customer identification documents produced is verified with original and certified as such are kept on records in branch/centralized location as per our policy,
along with the original customer relationship-cum-account opening form. The signature of the customer/s in form is verified and confirmed with the signature/s in the customer
relationship-cum-account opening form & finacle. I have verified the mode of operation of the account from the customer relationship-cum-account opening form & finacle. I hereby
confirm that the request form submitted herein is complete in all respects and all the relevant documents are obtained/available.

Entered By Verified By:

PPC: PPC

Signature: Signature

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The request dated ----/-----/-------- is received for the following service request/s in the account: Cheque book issue/Stop payment./Passbook Issue/Account Statement /SMS
deactivation/MPIN reset/ATM repin/ block/closure/Account Closure.

Signature of Officer:

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