RTGS/NEFT Application Form RTGS/NEFT Application Form

Date: Date:
A. Details of Applicant A. Details of Applicant
1. Name of Account ` 1. Name of Account
2. Account No. 2. Account No.
B. Details of Beneficiary B. Details of Beneficiary
1. Name of Account 1. Name of Account
2. Account No. 2. Account No.
3. Bank Name: 3. Bank Name:
4. Branch 4. Branch
5. IFSC Code 5. IFSC Code
6. Amount to be Remited Rs. 6. Amount to be Remited Rs.
Add Bank Charge Rs. Add Bank Charge Rs.
Total Rs. Total Rs.
Rupees Rupees

For Bank's Use Only For Bank's Use Only

Debited Appicant's A/c Total Rs. Debited Appicant's A/c Total Rs.
Date: Remittance No. Date: Remittance No.

Remit the amount as per above details by RTGS/NEFT by debiting my/our account for the amount of
remittance plus your charges. We agree to abide by the terms and conditions of transfer.

Conditions : Remitting banks shall not be liable for any loss of damages arising of reciting from delay in
transmission or delivery therefore in dephering the message from any cause whatsoever or from the mis-
interpretation received action of destination bank or any act beyond our control

Bank's Authorised Signatory Bank's Authorised Signatory Applicant's Signature