Application for National Electronic Fund Transfer/

Real-Time Gross Settlement Systems (NEFT /R,:GS) "AXIS BANK

To,
Immediate payment Service (IMPS)
T he Branch Head
______ Branch
Date I O I I
D MI M I Y I I I
Y Y YI

Dear Sir,
PAN*I I I I I I I I I I
*To be provided by Axis Bank customer
Please remit through NEFT/RTGS/IMPS a sum �--- ---- -Rupees In words)-'-.----�--------- -
--,-
---------------�--------------'---------only, as per details given below:

0 Cash* (Only for NEFT Transactions upto � 49999/-) 0 Cheque 0 Debit my/our account
*In case of cash, please fill in the pay-in-slip •cash only for NEFT per day
*To be filled by the Applicant in CAPITAL LETTERS *IMPS limit to t' 2 ._00 Lakhs only

DETAILS OF APPLICANT (REMITTER)

Account Number I I I -1 I
Cheque Number I I I ChequeDate I D I D I MI M I Y y y y

Remitter's Name
I I I I I I
I I I I I I I I
Address
I I I -I I -1- I I
Mobile/
I I I I I I I I I
Other Number I I I I I

0 DETAILS OF BENEFICIARY
Beneficiary's Name
I I I I I I I I I I I
I I I I I I I I I I I
Account Number I I r I I I I I I I I
Reconfirm Account No.I I I I I I I I I I I
Bank Name
I I I I I I I I I I I I I .I
IFSC Code (11 Digit} I I I I I
I
Branch Address
I I I I I I I I
Sender to Receiver information (if any): ----�---------�----------------------
TERMS AND CONDITIONS
This transfer is valid for a single transaction.
• The fund·transfer will be governed by the Terms and Conditions given on our website www.Axisbonk.com
� Due core is taken while filling up the beneficiary account number & IFSC code
• Transfer of on amount upta � 49,999----,---- --,in cash permissible using NEFT
• Photo ID proof to be given by non, customer for cash payment obove______against NEFT
• Please do not di"sclose your Accoun_t details/Internet Banking, User ID and Passwords/ATM debit-Card/Credit Cord/Mobile Banking/ Personal Information
t. o any person
• Do not foll prey to false promises; beware of dubious scheme
• In case the IMPS transaction goes in pending state, funds may get transferred or reverted bock within T + 2 days.
• Transfer of an amount upto � 2,00,000 is permissible per IMPS transaction, subject to per day transfer limit as per schem·e code

0
•
DECLARATION
I/We authorise Axis Bank to recover charges as may be applicable by debiting my account as mentioned above
• I/We understand ihot as per the RBI Circular doted October 14,2010, transfer of funds through electronic mode will be executed only on the basis of ihe account
number of the beneficiary provided while initiating the transaction. Nome will NOT be considered as o criteria for providing credit
• I understand thot this facility is _ovoiloble
, only at select location and banks covered under Electronic Funds Tronsfer focility offered
_ by RBI

CUSTOMER SIGNATURE(S)

Signoh.HB *{Primary .A,pp!icont)

Name Name Name

ACKNOWLEDGEMENT TO CUSTOMER

We acknowledge receipt of NEFT / RTGS/ IMPS instruction(s).

Reference No(For RTGS/NEFT) ........________ Retrieval.Reference No (For IMPS) __________ For Saksham Reference No (For IMPS)
Branch________� Name and Signature of Bank Official With Date & Ti_me Re quest . ·
Remitter's N9me____________ Account No._____________
. Che que No._____________
Beneficiary Name_ _ ________Account
. No. _ ___________IF SC________________
Amount in figures___________�Amount (In Words)__�-------------------------