CUSTOMER DETAILS: D D M M Y Y Y Y

*On-Boarding ID generated from IDP

*Account name as per Bank records

*Account Number for credit/debit funds

*Account Name (To be displayed in I-sure pay)

Cust ID

*Contact Name

*Registered Mobile Number

*Registered Email ID

*Account number to debit charges

*Tech Person Name (authorized to give tech details)

*Tech Person Contact number

*Tech Person email ID

Consultant code if applicable

Integration Required: (Select API)

Payment Collection Others

CIB Multimode Payment & Recon APIs eCollection API - Without validation Balance check

Composite Pay ( CIB+IMPS+UPI) eCollection API with validation (Message hold) Bank statement

IPS API (multi mode file based ) UPI collection OTP creation and validation

H2H IPAY payment Cash Deposit Machine (CDM) API AEPS | Adharpay

SFTP IPAY payment Cash & cheque collection with validation (Isurepay) Beneficiary Management

BBPS ( Bill Payment ) H2H eCollection eNACH

Direct Tax Payment Eazypay (Transaction settlement & refund API) Transaction alerts (Instaclear)
GST Payment with confirmation challan PG dynamic URL for collection ( Eazypay) Penny Drop

*Please select required options, if opted for CIB Payments API

Beneficiary Registration API Payment to Registered Beneficiary
*Please select required options, if opted for Composite PAY API
Mode of payment : UPI IMPS RTGS/NEFT
*Please select required options, if opted for UPI collection
 UPI collection via collect and QR  UPI collection via Dynamic VPA with validation  Cash@POS  UPI 2.0
*Please select mode if selected IsurePay API
Mode of acceptance : Cash ICICI Cheque Non-ICICI Cheque ICICI DD Non ICICI DD Debit Authorization
*Please select required options, if opted for Collection products
Purpose of collection: For own Business  As an aggregator on behalf of merchants
Business descryption_________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Industry Type: Manufacturing  e-Commerce Trader  IT  Other ________________________
Note: In case of Aggregator profile of client, Attached Collection Annexure is to be signed and provided along with Application form

* Integration charges (Applicable for testing and TSP support valid for 60 days from the date of application form)
Setup/ Product Setup/ Implementation charges Transaction charges (Define flat or per Rs 1000 basis)
1.
2.
3.
 For eNACH:
Setup/ Implementation charges Mandate charges (Per mandate) Transaction charges (per transaction)

*Technical specifications as applicable:

*UAT IP (Please provide comprehensive list
of IPs that will be used for integration)

*Production IP (Please provide

comprehensive list of IPs required for live
integration)
*UAT port
*Production port
*UAT return URL/ callback URL
*Production return URL/ callback URL
*UAT push URL
*Production push URL
*Public IP for SFTP access (Only for IMPS
API)
For Tax Payment

Corp ID

User ID Standard API user creation

Workflow limit for the User Always unlimited for tax payment

*Please attach Technical Requisition document as per applicable product

DECLARATION:
 I / We hereby declare that all the particulars and information given in the Application are true, correct, complete and up-to-date in all respects and I / We have not
withheld any information
 I / We agree and undertake to provide any further information that ICICI Bank Ltd. / its Group Companies May require
 I / We agree and understand that ICICI Bank Ltd. / Group Companies reserve the right to reject any application without providing any reason
 I / We agree and understand that I / We have to complete further applications for specific credit facilities / investments or liability products / services from ICICI
Bank Ltd. / its Group Companies, as prescribed from time to time
 I / We agree and understand that ICICI Bank Ltd. reserves the right to retain the Application, and the documents provided therewith including photographs, and
will not return the same to me / us
 I / We have read, understood and hereby agree to terms and conditions governing the ""Cash Management Services"", “”UPI””, “”IMPS”” & “”AEPS”” “API Service”
together with Terms and Conditions pertaining to “Current Account” and “Corporate Internet Banking” as displayed on www.icicibank.com and agree to abide by
the same
 I / We understand that the said terms are subject to revision from time to time and I / we agree to keep ourselves updated of such changes and be bound by the
terms as are in force from time to time
 Save and except to the extent as disclosed in this Application or in such further applications by me / us to ICICI Bank, I / we (if a person other than a subsidiary of
ICICI Bank, or a section 25 company or a Government company, or in cases of Facility/ies not encompassed by the restrictions specified by the Reserve Bank of
India from time to time) represent that: no director or a relative / near relation (as specified by the Reserve Bank of India) of a director of a banking company
(including ICICI Bank) or a relative / near relation (as specified by the Reserve Bank of India) of a senior officer of ICICI Bank (as specified by Reserve Bank of India)
is a partner of mine / us, a director, manager, employee of mine / us or of a subsidiary of me / us, or of the holding company of me / us, or a guarantor on behalf
of / for / to me / us, or holds substantial interest, in me / us or a subsidiary or holding company of me / us
 I/We undertake that we shall not, without the prior written consent of ICICI Bank, display or disclose all or any part of any confidential information including the
APIs shared with us, in any manner or circumstances whatsoever, to any person or any third party and the confidential information shall be used by us, solely for
the purpose captured herein.
 I / We declare that I / we have had no insolvency proceedings initiated against me / us nor have I / we ever been adjudicated insolvent
 I / We agree, undertake and authorize ICICI Bank / its group companies to exchange, share or part with all the information, data or documents relating to my / our
application to other ICICI group companies / banks / financial institutions / credit bureaus / agencies / statutory bodies / such other persons as ICICI Bank / its group
companies may deem necessary or appropriate as may be required for use or processing of the said information / data by such person(s) / or furnishing of the
processed information / data / products thereof to other Banks / Financial Institutions / credit providers / users registered with such persons and shall persons and
shall not hold ICICI Bank Ltd. / its Group companies liable for use of this information
 I / We hereby declare that all the particulars and information given in this Application with respect to the GSTIN / UIN / SEZ number and the billing address is
correct and ICICI Bank can update the same in its record.
 In case my / our PAN is not updated for availing Cash Management Services, please update the same as mentioned in this ApplicationI / We hereby declare
that the information provided can be used by ICICI Bank for the purposes of charging GST and reporting of transactions on the GSTN portal and for other related
aspects in relation to reporting as stated under the CGST Act 2017,the SGST Acts and the applicable rules in this regard In case my / our PAN is not updated for
availing Cash Management Services, please update the same as mentioned in this Application
 I / We are aware of charges applicable for banking services and I / we further authorize ICICI Bank to debit my / our account(s)towards any charges for the selected
services.
 I / We further agree that if any additional / customized facilities are availed by me / us, I / we shall be charged separately for such additional / customized facilities
 I/ We have read the Application form and am/ are aware of all the terms and conditions for availing this facility.
 I/ We have not at any time been in non-compliance of the applicable rules/ regulations/ guidelines in force from time to time, as framed by the Reserve Bank of
India
 I/ We also understands that continuation of the facility provided in pursuance to this Application Form is at ICICI Bank’s sole discretion and in case ICICI Bank is
dissatisfied with our conduct of the facility, ICICI Bank has the right to close the Facility after giving me/ us 15 days’ notice.
 I/ We agrees and undertakes to pay the IMPS Transaction fees for the Services provided by the ICICI Bank by RTGS/Bank Transfer/cheque only.
 I/We shall process the invoice and make payments within a period of Seven ( 7 ) working days from the date of the receipt of the invoice raised by the ICICI Bank.
Failing which ICICI Bank shall be entitled to debit our account held with ICICI Bank for the pending invoice amount with no further notice and shall in no way be
liable or responsible for any direct, indirect, special or exemplary losses that may occur to me/ us as a result of such debit.
 ICICI Bank shall not be liable for any financial loss, damages, claims, liabilities and expenses that may be suffered by me/us as a result of me/us opting for the
services of any third party vendor including but not limited to any technical support whatsoever provided by such third party vendor or as a result of us exposing
any IT infrastructure or sharing any data to such third party vendor for the purpose of API integration.
 I/We declare, confirm and agree that. I/We understand that certain particulars given by me/us are required by the operational guidelines governing banking
companies.
 That the existing Account details registered with ICICI Bank (including the authorised signatories and their respective transaction limits) remain unchanged.
 I/We declare that, I/we am/are duly empowered to avail of this API Service or terminate the same and at no point of time shall I/we challenge/question ICICI Bank
for provision of this API Service or for doing any transactions thereunder on my/our request.
 I/We hereby agree, undertake and authorise ICICI Bank Limited to make payments by debiting the Accounts as per the instructions contained in the transaction file
transferred though the API Service from our server and hereby agree and undertake that we shall be bound by any and all actions taken pursuant to such requests
even if such requests have been countermanded by a subsequent instruction or written instruction or direction of ours. Such instructions shall be sent as per ICICI
Bank’s prescribed format and we shall comply with such authentication procedures as may be prescribed by ICICI Bank from time to time for purposes of
transmitting such transaction files through API Service.
 I/We agree to hold ICICI Bank harmless and indemnify ICICI Bank against any and all suits, costs, claims, proceedings counterclaims, actions, losses, damages,
liabilities, demands, expenses, third party claims or penalties from regulators (including, without limitation, attorney’s fees and court costs) whatsoever which ICICI
Bank may suffer / incur on account of it executing such instructions received through our platform under API service.
 I/We agree and confirm that all activities undertaken by us or our partners/merchants, the customers or through the applicati on programming interface (“API(s)”)
provided to us by ICICI Bank for facilities provided shall be undertaken by us only for the purposes subscribed through this form (“Purpose”). I/We shall not use the
APIs any other purpose other than the Purpose mentioned herein (including but not limited to domestic money transfer transactions). We hereby undertake to
indemnify and hold ICICI Bank harmless against any claims including third party claims, losses, damages, costs, charges, expenses or liabilities arising from non-
compliance or breach of the terms herein any non-compliance/breach of applicable laws.
 Set-Off and Lien:
a) ICICI Bank and its group companies shall have the paramount right of set-off and lien, irrespective of any other lien or charge, present as well as future on the
deposits of any kind and nature (including fixed deposits) held/ balances lying in any accounts of the Client, whether in single name or joint name(s) and on any
monies, securities, bonds and all other assets, documents and properties held by/ under the control of ICICI Bank and/or its group companies (whether by way of
security or otherwise pursuant to any contract entered/ to be entered into by the Client in any capacity) to the extent of all outstanding dues, whatsoever, arising as
a result of any of ICICI Bank's or its group companies’ services extended to and/or used by the Client and/or as a result of any other facilities that may be granted
by ICICI Bank and/or its group companies to the Client. ICICI Bank and/ or its group companies are entitled without any notice to the Client to settle any indebtedness
whatsoever owed by the Client to ICICI Bank and/or its group companies, (whether actual or contingent, or whether primary or collateral, or whether joint and/or
several) hereunder or under any other document/ agreement, by adjusting, setting-off any deposit(s) and/or transferring monies lying to the balance of any
account(s) held by the Client with ICICI Bank and/or its group companies notwithstanding that the deposit(s)/ balances lying in such account(s) may not be expressed
in the same currency as such indebtedness. ICICI Bank's and its group companies’ rights hereunder shall not be affected by the Client’s bankruptcy, death or winding-
up. It shall be the Client’s sole responsibility and liability to settle all disputes/ objections with any such joint account holders.
b) In addition to the above mentioned right or any other right which ICICI Bank and its group companies may at any time be en titled whether by operation of law,
contract or otherwise, the Client authorizes the Bank: (a) to combine or consolidate at any time all or any of the accounts and liabilities of the Client with or to any
branch of ICICI Bank and/or its group companies; (b) to sell any of the Client’s securities or properties held by the Bank by way of public or private sale without
having to institute any judicial proceeding whatsoever and retain/appropriate from the proceeds derived there from the total amounts outstanding to ICICI Bank
and/or it group companies from the Client, including costs and expenses in connection with such sale; and (c) in case of cross currency set-off, to convert an
obligation in one currency to another currency at a rate determined at the sole discretion of ICICI Bank and/or its group companies.
 I/We undertake that data pertaining to any tax payments won’t be hosted on our server outside India nor it will be hosted on cloud.
 I/We confirm that we shall not make any false representation to our customers through challan or debit advice provided by ICICI Bank and challan/debit advice
shall be provided in the same format as shared by ICICI Bank.
 I/We confirm that we will not affix any seal or make any other modification to the challan or debit advice received from ICICI Bank.
 I/We hereby declare, confirm, and agree that the acknowledgement / status of payment shall be updated to our customer (through API service) as and when the
transactions initiated through our platform are completed / delivered.
 I/We undertake that customers will be notified that transactions will be completed only once the API is triggered from our side.
 I/We also undertake that ICICI Bank will be provided clear funds prior to the processing of each transaction initiated by us or our customers.
 I/We confirm that the tax transaction would be initiated through ICICI Bank on the same day as the day on which our account is credited by our customers for
payment of such taxes.
 I/ We understand that in case of any changes/addition/modification/deletion initiated by regulator or Bank, the same will be replicated at our end within stipulated
timelines and may affect transaction processing for the referred period.
 I/We acknowledge that ICICI bank reserve rights to provide the additional services of any further challan payment as provided by regulator.
 I/We understand that under direct tax API, challan ITNS 280, 281, 282, 283 shall be covered. Any challan which needs to be initiated from the regulator portal and
any additional challan under referred challan type shall not form part of the services herein.
 I/We understand that transaction API will be processed between 4 am till 11 pm. I/We shall ensure to send these API within stipulated time. I/We confirm that we
will not be charging customer for tax payment
 /We confirm that we are not in business of spa, escort services, friendship club, adult entertainment industry, network marketing, lottery, multi-level marketing, or
money transfer business (like accepting money and transferring to other beneficiaries/deposit into banks etc.); cryptocurrency/virtual currency, virtual asset
dealings; chitfund/nidhi company; fantasy games (except those which are purely subscription based and do not offer rewards, prize money, winning or any other
consideration in cash/kind to the player); betting; dealing in marijuana; unregulated/unlicensed money service business or money & value transfer services like
exchange houses, remittance agents, or individuals running such business, unlicensed financial institutions, foreign exchange services, unlicensed banking activity,
loan apps not having relevant licenses; shell entities/firms, money mules, incorporated/registered or national of any jurisdiction included in the Financial Action
Task Force “Black List”
 I/We shall provide the complete list of Merchants to Bank in prescribed format and obtain the prior approval from ICICI Bank for each Merchant in case of aggregator
profile
 I/ We understand that my/our country of operations is / shall be as per the regulatory requirements as laid down by Reserve Bank of India(“RBI”).
 I/We confirm and declare that no officer / director / employee / agent / representative of ICICI Bank or relatives of such officer / director / employee / representative,
and no public official, in India or elsewhere, or relatives / representative of such public official or any third party connected with a public official, in India or
elsewhere, has: (a) received, (b) been induced to receive, or (c) would receive, anything of value of any kind, directly or indirectly, from me/us or my/our personnel
or any person connected with me/us in connection with the transactions contemplated among ICICI Bank and me/us under the API services provided by ICICI
Bank; none of the aforesaid persons have a business relationship of any kind with me/us.
 I/We confirm that I/we shall not use ICICI Bank’s name without its prior written approval.
 I/We confirm that any requests content for external communication (including verbal communication such as media interviews) which mentions the name and
logo of ICICI Bank, like, press releases, case study on website, social media posts among others shall be shared with ICICI Bank for their views and approvals.
 I/We undertake that we shall not use ICICI brand name without authorization and approval from ICICI Bank and acknowledge that ICICI Bank holds the right to take
action against the same.
 I/We confirm that ICICI Bank’s name shall not be used(wherever used pursuant to prior written approval of ICICI Bank) once relationship with ICICI Bank has been
terminated. I/We shall remove any mention of ICICI Bank or ICICI Bank logos from my/our websites, social media and other written external communication post
such termination.

I confirm that the application and related documents have been executed at (place) by person signed below, in my presence
on the date mentioned below and verified with customer signature available with Bank account. All the information in the Application form
have been validated with customer bank account.
Date:
 COLLECTION COMPLIANCE ANNEXURE

The Aggregator hereby agrees/understands/confirms that:

1. The Aggregator and any of the merchants on-boarded by the Aggregator (“Merchants”) for the use of
the Collection Facilities (defined below) does not directly provide any services or has any dealings with
any entity which has the below mentioned business profiles/does not deal with the following services:
spa, escort services, friendship club, adult entertainment industry, network marketing, lottery, multi-level
marketing, or money transfer business (like accepting money and transferring to other
beneficiaries/deposit into banks etc.); cryptocurrency/virtual currency, virtual asset dealings;
chitfund/nidhi company; fantasy games (except those which are purely subscription based and do not
offer rewards, prize money, winning or any other consideration in cash/kind to the player); betting; dealing
in marijuana; unregulated/unlicensed money service business or money & value transfer services like
exchange houses, remittance agents, or individuals running such business, unlicensed financial
institutions, foreign exchange services, unlicensed banking activity, loan apps not having relevant
licenses; shell entities/firms, money mules, incorporated/registered or national of any jurisdiction included
in the Financial Action Task Force “Black List”.
“Collection Facilities” refers to collection product (like eCollection, UPI collection API) that facilitates
Aggregators to get the funds via Virtual Account Number (Identifier for payer or transaction) from
Merchant through inward NEFT/RTGS/IMPS/FT/UPI in their account.
2. Payments pursuant to the Collection Facility shall be directly settled into the Merchant accounts only. The
Aggregator shall be responsible for know-your-customer compliances (“KYC”) of the Merchants as per
applicable laws and in accordance with the guidelines shared by ICICI Bank. The Aggregator shall on-board
such Merchants and more and shall without any delay share the KYC details to ICICI Bank time to time, as
and when required by ICICI Bank.
3. The Aggregator would be responsible to retain the digital/physical KYC documents, as prescribed by ICICI
Bank from time to time, in the event the Aggregator does not have a duly approved policy for conducting
Merchant KYC, and as required under applicable laws. ICICI Bank would monitor the prescribed KYC
process by auditing the Aggregators records on a periodic basis, analyzing a sample of the Merchants
documents at sole cost of the Aggregator. ICICI Bank shall have the right to inspect and/or audit all records
of Aggregator that relate to arrangement captured and transactions processed under pursuant to
Collection Facility, at any time and for such purposes the Aggregator shall fully cooperate and support
ICICI bank with requisite records/information requested during such audit/inspection.
4. ICICI Bank shall share a prescribed list of documents as per its internal policies and practices to be collected
by the Aggregator at the time of Merchant on-boarding. The Aggregator shall adhere to the same in strict
compliance.
5. The Aggregator clearly understands that before extending the Collection Facility to the Merchant the
Aggregator shall provide the complete list of Merchants to Bank in prescribed format and obtain the prior
approval from ICICI Bank for each Merchant.
6. The Aggregator shall ensure that in the event Merchant fails to fulfill any of the criteria mentioned herein
and/or process prescribed by ICICI Bank herein, the Collection Facility shall not be made available to such
Merchant by the Aggregator.
7. The Aggregator understands that the Aggregator/Merchant shall be on-boarded by ICICI Bank in for
provision of the Collection Facility through e-collection validation mode only. In the event an
Aggregator/Merchant requires the e-collection Facility extended to it in non-validation mode, the
Aggregator/Merchant may request for such mode however, granting such request shall be at the sole
discretion of ICICI Bank.
8. The Aggregator shall ensure that settlement of the collection amount will be done in the account of
respective Merchant only on whose account amount is collected.

Date:
________________________________
Authorized Signatory
(Rubber seal of company required)