RTGS ACCOUNT VERIFICATION & PAYMENT INSTRUCTION SLIP

The Ma na ge r
Ba nk Na me : ___________________________________________
Bra nch Name : _________________________________________
Loca tion : ______________________________________________

I _____________________________________________________________ (Account Holder Nam e),residing

at------------------------------------------------------------------------------------------------------------------------------------------------------------
have applied for a Personal Loan of Rs.---------------------------, (Rupees-------------------------------------------------------------
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authorize ICICI Bank to CREDIT my account for payments received through RTGS (Real Time Gross Settlement)
as per the details given as under.

Account Type S avings / Current / Over Draft :

Beneficiary Details :
Beneficiary Nam e :
Credit Account No. :
Centre (Location) :
Bank Nam e :
Branch :
Account Type :
MICR CODE :
IFS C Co d e :
Rem arks / Narration

I hereby declare that the particulars given above are correct and com plete. If the transaction is delayed or
not effected at all for reasons of incom plete or incorrect inform ation, I w ould not hold the user institution
responsible. I have read the option invitation letter and agree to discharge the responsibility expected of
m e as a participant under the schem e.

(…………………………………) (…………………………………) (…………………………….) (….…………………………)

S ignature of the Custom er (Account Holder/s)
Date

Date S ignature of the Authorized official from the Bank