Application Form for Payment Instruction Bank Copy

BD-RTGS BEFTN Date D D M M Y Y Y Y

Branch Name: Time H H M M

Sender's Details Receiver's Details

Account No.: Bank Name: Routing No.:
Account Name: Branch Name:
Currency: Amount: Account No.:
Amount in words: Account Name:
Address (Optional):
Purpose: Only for NBR Payment
Mobile No.: Customs Office Code (3 digit): Registration Year (4 digit):
Fee: VAT: Registration Number (Max 12 digit) :
Total Amount : Amount+Fee+VAT Declarant Code (Max 18 digit):
I / We hereby authorize BASIC Bank Limited to debit the total amount (amount + fee + VAT) from my/our above mentioned account to carry out the BD-RTGS /
BEFTN transaction as per details mentioned above. I / We acknowledge that BASIC Bank Limited has no liability for any consequences arising out of erroneous
details provided by me/us.

Signature(s) of the Sender(s)/Applicant Signature of the Receiving Officer of the Bank

(Please affix stamp wherever applicable)
Bank use only

Signature verified by Transaction done by (in KCBS) Transaction approved by (in KCBS)

Message prepared by (in RTGS/EFTN) Message Checked by (in RTGS/EFTN)

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Application Form for Payment Instruction Customer Copy

BD-RTGS BEFTN Date D D M M Y Y Y Y
Branch Name: Time H H M M

Sender's Details Receiver's Details

Account No.: Bank Name: Routing No.:
Account Name: Branch Name:
Currency: Amount: Account No.:
Amount in words: Account Name:
Address (Optional):
Purpose: Only for NBR Payment
Mobile No.: Customs Office Code (3 digit): Registration Year (4 digit):
Fee: VAT: Registration Number (Max 12 digit) :
Total Amount : Amount+Fee+VAT Declarant Code (Max 18 digit):
I / We hereby authorize BASIC Bank Limited to debit the total amount (amount + fee + VAT) from my/our above mentioned account to carry out the BD-RTGS /
BEFTN transaction as per details mentioned above. I / We acknowledge that BASIC Bank Limited has no liability for any consequences arising out of erroneous
details provided by me/us.

Signature(s) of the Sender(s)/Applicant Signature of the Receiving Officer of the Bank

(Please affix stamp wherever applicable)