ELECTRONIC PAYMENT REQUEST FORMAT

(TO BE FILLED IN CAPITAL LETTERS)

All Fields are Mandatory

EIPVENDOR CODE
(Refer PO / WO to know vendor code)

Name of the Organization …………………………………………………………………………

Complete postal address with …………………………………………………………………………

PIN Code. (Please provide PERMANENT
ADDRESS). …………………………………………………………………………

E-mail ID to communicate the payment …………………………………………………………………………

Contact No:

Type of Organization Sole Proprietor Firm Partnership Firm Private Limited

Public Limited Others (Pl specify)

Ifit is a Partnership Firm, please ensure that all the Partners sign in this Format.

Bank Name: ………………………………………………………………………………………………………….

Full Bank A/C No:

IBAN:

SWIFT

Correspondent Bank details (Not applicable for GCC Currencies / USD / EUR / GBP / JPY)

1. Bank Name ………………………………………………………………………………………………….

2. Swift Code …………………………………………………………………………………………………..

Account Title: ………………………………………………………………………………….

Bank Address: ………………………………………………………………………………….

(Complete postal address)
………………………………………………………………………………….

………………………………………………………………………………….

We hereby accept to receive our payment through Electronic Fund Transfer system. We shall intimate to
you immediately in case of any change in the above particulars.

Place:
Date: (Name & Signature by Authorized Signatory with Seal)

Sensitivity: LNT Construction Internal Use