Request for Auto Debit facility

Credit Cards

To
The Manager, Credit Card Operations
Axis Bank Ltd.

I wish to avail the Direct Debit facility from my Savings/ Current Account. Kindly debit my
Savings/Current account towards Credit Card Outstanding for the following amount:

100% of the due amount

Minimum amount due

Please mention the 15 digit AXIS Bank Account number for Direct Debit

1. Name:

AXIS BANK CREDIT CARD NUMBER:

Date:

Signature of Account Holder:

Signature of Joint Account Holders:

1 2

Name of Joint Account Holders:

Signature of Joint Account Holders: 3 4

Name of Joint Account Holders:

You can fax/e-mail/courier the form to:

Credit Card Customer Service
Axis Bank Ltd, NPC 1, 5th floor, Gigaplex, plot No.I.T.5
MIDC, Airoli Knowledge Park, Airoli, Navi Mumbai- 400708
Fax: 022-71315270
Email: www.axisbank.com/support
Contact No: 1860-419-5555 or 1860-500-5555