BANK OF INDIA BANK OF INDIA Branch Date : Branch STAR INSTA REMIT APPLICATION FORM Dat (To be filled in by the Applicant in Block Letters) fate : | Details of Applicant (Remitter) : Received from (1) Title of Account | (2) AccountNo,___Type of Account*Savings / Current / Cash Credit / Over Draft | Details of Beneficiary ad” | [ey Beneticianys By Cheque Transfer for star Name Insta Remiton__________[(@)AVe.No. @) Bank (4) Branch Centre" = (Bran | ‘@) Branch Address a Favouring, > [IFSC Code] (7) Type of A/c] *Savings/CurrenvCash Credit/Overdraft| ( (Amount to be remitted : Rs. x 5 (Rupees. | — Bank | Remit the amount as per above details by debiting my/our account for the amount of remittance plus your charges | | My Mobile No, Branch | | Authofised Signatory Alc No. | | FOR BANK'S USE ONLY Amount Rs. |. Debited Applicant's Alc. | Date of Transfer___MBB Transaction No.. SFMS UTR No.. Charges Rs. Total Rs. | Authorised Signatory * Strike off which is not applicable ‘Authorised Signatory