BANK ACCOUNT INFORMATION

EMPLOYEE INFORMATION
Name: Start Date:
Position: CostPoint ID:

BANK ACCOUNT DETAILS

Please fill complete and relevant information in below columns. Cuttings/ omissions will not be
accepted. Salary will only be transferred to account owned by employee, NO joint account or
account of any other employee or relative will be entertained. Please attach a cancelled cheque
leaf for the verification of account.

TITLE OF ACCOUNT

ACCOUNT NUMBER

TYPE OF ACCOUNT  Current  Saving

BANK

BRANCH/ LOCATION

BRANCH CODE

SWIFT CODE

CURRENCY

I certify that the above Account detail given by me is true, complete and correct to the best of
my knowledge and belief. I understand that International Medical Corps will not be responsible
if I share incorrect/ incomplete details.

EMPLOYEE NAME (PRINT IN CAPITAL LETTERS)

EMPLOYEE SIGNATURE