CREDIT FACILITY APPLICATION FORM

PO Program Education Loans

Facility Application No.:

Date: D D D D Y Y Y Y

Facity Amount Required: 2 5 5 5 0 0

I. INTRODUCTION
1. ICICI Bank Limited (“ICICI Bank”) – Branch / Office address:....................................................................................................................................
2. ...................................................................................................................................................................................................................................
All applicants [collectively, “the Applicant(s)”, which expression shall, as the subject or context may admit or require, mean any or each of the
Applicant/s]- whether individuals, proprietary concerns, partnerships, Hindu Joint Family, societies, trusts or private/public companies or any
other bodies or associations (whether incorporated or not), who wish to either avail of financial assistance detailed below (the “Facility”) from
ICICI Bank for any purpose specified below in this Application Form (the “Purpose”) are required to fully fill-in and submit this Application Form
(and along with all other necessary details and documents) to ICICI Bank for applying for the same.
3. ICICI Bank shall be entitled at its sole and absolute discretion to reject/approve any Application Form submitted by the Applicant(s).
4. Upon consideration of the Application Form and all other additional documents necessary or required for consideration of the Application Form,
submitted by the Applicant(s), and if the same is to the satisfaction of ICICI Bank, ICICI Bank shall disburse the requested Facility to the
Applicant(s).
5. The Applicant(s)'s request for the Facility vide this Application Form, and the sanction of the same by ICICI Bank and/or disbursement of
theFacility, shall be subject to and governed by “ICICI Bank Limited's (All-India) Standard Terms & Conditions Governing education loans
[Registered on 12.05.2011 with the Sub-Registrar-VII, New Delhi/Delhi vide registered document No. 441 in additional Book No. 4 Vol No.1447
at page 92 to 104]
6. All capitalised terms used but not specifically defined in this Application Form shall have the respective meanings ascribed to them under the
Standard Terms.

IA PERSONAL DETAILS OF THE APPLICANT (FOR STUDENTS)

Prefix First Name Middle Name Surname

Name
Father’s / Spouse Name
Mothers’s Name
Applicant’s Maiden Name
Date of Birth D D M M Y Y Y Y Gender: Male Female Transgender Marital status Married Single Others (Pls.
sign
Education: Post Graduate Professional Diploma Holder Graduate Under Graduate/ Matriculate here)
1
Customer Category: General SC ST OBC MBC Others
Religion: Hindu Muslim Sikh Zorastrian Christianity Buddhist Others
Current Address

City/ Town/ Village District State Code Pin

Nearest Landmark STD Code Tel
Permanent Address
District State Code Pin
Nearest Landmark STD Code Tel
(Pls.
City/ Town/ Village Location Category: Rural Semi-urban Urban Metro sign
here)
Mobile No. Email ID 2
Residential status: Resident Individual NRI PIO Foreign National UID No.

IB COURSE DETAILS

Institution/ University(N) M A N I P A L A C A D E M Y O F H I G H E R E D U C A T I O N

Name of the Course P O S T G R A D U A T E D I P L O M A I N B A N K I N G

Duration of Course 0 1 Yrs Mths Country: I N D I A

Date of commencement of course Level Of Course: Graduate Post Graduate Professional

Course Approved by: UGC Govt. AICTE Other Type of Course: Medical Engineering Management
Others
 IC. COURSE COST DETAILS
st
2nd Year / 3rd Year / th th
Cost Details 1 Year / 4 Year / 5 Year / Total
Sem./ Trimester Sem./ Trimester Sem./ Trimester Sem./ Trimester Sem./ Trimester

Tuition Fees 137500 118000

Examination Fees

Cost of Study Materials

Traveling Expenses

Others if any

TOTAL 1

Funds available with Self

Scholarship

TOTAL 2

GRAND TOTAL (TOTAL 1 - 2) 255500

II PERSONAL DETAILS OF THE PARENT/ GUARDIAN

Prefix First Name Middle Name Surname
Parent/ Guardian Name

Parent/ Guardian Current

Address

City/ Town/ Village District State Code Pin

Nearest Landmark STD Code Tel
Parent/ Guardian
Permanent Address

City/ Town/ Village District State Code Pin

Nearest Landmark STD Code Tel

Mobile No. Email ID

Relationship with applicant: Father Mother Brother Spouse Sister Others (Pls.
sign
here)
III DETAILS OF THE FACILITY AND OTHER CHARGES (Facility in the nature of : Rupee Loan) 1

Facility amount: Not exceeding ` Two Lakhs Fifty Five Thousand and Five Hundred Only
..................................................................................................................................
255500................. In Words only.
Rate of Interest: .......................................% per annum In Words .......................................................................................................................only.
(plus applicable interest tax or other statutory levies) payable on the date(s) specified in Section below in relation to repayment of the Facility.
Tenure:....................................
NIL
Processing fee:Rs_____________ NIL
In Words................................................................................................................................only.
(Plus applicable taxes or other statutory levies, if any.)
Note:The processing fee is one time fee and is collected by ICICI bank for the purpose of appraising the application for the
facility and the same is independent of the outcome/ result of such appraisal.

Purpose of the Facility: Education

..................................................................................................................................

Facility is to be disbursed to :
Manipal Global Education Services Private Limited
Name: ............................................................................................................... Amount: ...255500 .....................................................................................
Disbursement Mode:
Direct credit to Manipal Bank a/c no. 0 0 0 2 0 5 0 0 2 2 8 6
ICICI BANK LIMITED
Bank ................................................................................................................ Bangalore
Branch ........................................................................................................
ICIC0000002
IFSC ................................................................................................................ MICR ........................................................................................................

Note: Fees/charges paid by deducting the Facility, then ICICI Bank shall disburse an amount reduced by the amount of fees/charges; however,
the Applicant shall be liable for the entire Facility amount.
 Repayment

Amount of each Installment(Post Moratorium): ` ...............................In Words only........................................................................................................

60
No. of Installments(Post Moratorium) ............................... 5th
Due date(s) : .................................. day of each successive month.

First Due Date: ................................. Last Due Date: ...............................................

Note: The Facility and applicable interest shall be payable/repayable by the Applicant(s) to ICICI Bank as per the aforementioned schedule
notwithstanding the date(s) of disbursement by ICICI Bank to the person(s) as mentioned above. Pre-EMI and EMI amount is basis sanction amount.

Mode of Payment / repayment of the Installments (Please select any one of the options mentioned below):
by direct debit from the applicant/s' bank account with ICICI Bank (“Direct Debit method”)
by deduction from the applicant/s' salary (“Salary Debit method”)
Direct payment by cash/cheque/draft in favour of ICICI Bank
any other method_____________________________________________________________(please specify)

Note:
I. The charges / interest rate(s) specified in this application form and / or the other transaction documents in relation to the Facility are
non-refundable in nature and the rates are changeable, at the discretion of ICICI Bank, from time to time. ICICI Bank shall endeavour to give notice
of such changes. All such charges shall become payable on / before the Due Date falling after the Due Date that such charges become payable.

ii. The charges for missed due date shall be payable by the Applicant/s to ICICI Bank under the ECS method, Direct Debit method, the Salary Debit
method and any other payment method selected by the Applicant/s (except the PDC method) for every instance that Installment/s is/are not paid
to/received by ICICI Bank in accordance with the repayment schedule specified above (irrespective of the reasons for such non-payment/
non-receipt).

iii. The cheque re-presentation charges shall be payable in each instance that any post-dated cheque is dishonoured (under any of the payment
modes) and consequently represented OR in each instance that a post-dated cheque is presented when any Installment/s is/are not received by
ICICI Bank by/upon issue of debit instructions under the ECS method or Direct Debit method or any other payment method (other than the PDC
method) selected by the Applicant/s for any reasons whatsoever. iv. Service tax and all other applicable taxes / statutory levies, if any, will be
charged additionally.
 SCHEDULE I / The Standard Terms shall stand modified as follows:
Clause 35 stands modified as follows;
The Bank reserves the unconditional right to cancel the Limits advanced/ to be advanced under theTransaction Documents (either fully or partially) without giving
any prior notice to the Borrower, on the occurrence of any one or more of the following :
(I) in case the Limits/part of the Limits are not utilised by the Borrower; or
(ii) in case of Deterioration in the Creditworthiness of the Borrower in any manner whatsoever; or
(iii) in case of non-compliance of the terms and conditions of the Transaction Documents.

For the purpose of this clause, Deterioration in the Creditworthiness shall mean and include without limitation, the following events:
(a) downgrade of the rating of the Borrower by a Credit Rating Agency;
(b) inclusion of the Borrower and/or any of its Directors in the Reserve Bank of India's willful defaulters list; closure of a significant portion of the Borrower's
operating capacity;
(c) decline in the profit after tax of the Borrower by more than fifteen percent;
(d) any adverse comment from the Auditor; and any other reason/ event in the opinion of the Bank constituting or which may constitute Deterioration in the
Creditworthiness;
(e) Following term stands amended as follows- “Transaction Documents” include all writings and other documents executed or entered into, or to be executed or
entered into, by the Borrower(s) or any other person or any other document executed or issued by ICICI Bank/Bank in relation, or pertaining, to the Facility
and each such Transaction Documents as amended from time to time.

I/ We have read and understood the concepts and illustrations in relation to due dates, classification of borrowal accounts as SMA (special mention account),
NPA (non-performing asset) as detailed in Annexure . I/ We further understand that the clarifications/examples mentioned in Annexure are only illustrative in nature
covering common scenarios and the norms and clarifications provided by Reserve Bank of India from time to time will prevail.

Execution/Signature/Affixation of thumb print by/of the Applicant

Signature (Applicant)

Name:...........................................................

TEAR-AWAY ACKNOWLEDGMENT
(to be given to/retained by the Applicant) Sr. No. ____________
Dear Sir(s)/Madam:
This is to acknowledge receipt of your Credit Facility Application Form and thank you for the same. If considered, our representative/s shall be in touch
with you in connection with the same.

DSE Signature _________________________ DSE Name: _________________________DSA Name: _________________________

SE Phone No: _________________________ Location: ___________________________
DSA Stamp: ___________________

[1] For individuals/sole proprietors

 ICICI BANK DIRECT DEBIT EMI & SECURITY MANDATE FORM

DATE : __________________

FROM
Customer Name :
Customer Address :

TO
ICICI Bank Limited.,
, Branch, , City.

Ref: Account No.:

Dear Sir,

I/We would like to inform you that we have taken a Car/Home/Consumer Durable/ Personal
Loan/Education Loan from ICICI Bank Limited Car/Home/Consumer Durable/ Personal
Loan/Education Loan Division pursuant to the Credit Facility Application Form (No. ___________
dated ____________) (the “Application Form’’) OR Facility / Loan Agreement dated ____________
(the ‘’Facility Agreement’’), submitted to ICICI Bank Ltd. You are hereby authorized to debit the
above mentioned account and credit ICICI Bank Ltd. – PDC account number
____________________ on receiving instructions from ICICI Bank Limited Car/Home/Consumer
Durable/ Personal Loan/Education loan Division towards: (i) the repayment of the Facility, the
Equated Monthly Instalment, instalment(s), Pre EMI interest, all interest and other charges
payable by me or to you over the entire tenure of Facility (“EMI Mandate”) and/ or (ii) any
default committed by me in repayment of dues (“Security Mandate”). The above mentioned
account will be debited with the amount Rs per month for repayment of dues
(Rupees__________________________________) and /or with the amount Rs.________________
(Rupees ____________ ________________________________only) for default in repayment of
dues, as the case may be, w.e.f. __________________ over the entire tenure of the Facility.

In the event of the above account getting closed/transferred for any reason, I/We will intimate to
the bank the new account opened with the bank to debit the loan repayment amounts.
Further, I/We undertake to submit the fresh set of Mandate for such new account, in lieu of
existing instructions.

We are requesting and hereby authorizing ICICI Bank Limited Car/Home/Consumer Durable/
Personal Loan/Education loan Division to forward this to you after affixing the signatures of
their authorized person(s) to signify their approval for the above instructions and agreement to
give effect to the above.

Please note that the Security Mandate will be invoked & banked only in specific circumstances
such as customer failing under default, exceeding overdue limit, etc. In case of default,
outstanding amount including overdue interest, bounces and other charges, if applicable, will
be debited.

I/We authorize ICICI Bank to upgrade my / our account whereby I / we will not be charged for
non-maintenance of a monthly average balance in savings account*.

*For detailed Terms & Condition of ICICI Bank Home Assure Savings Account visit
www.icicibank.com
Thanking you,
Yours truly,

_______________
Customer Name :
(Account Holder/s)
Signature & full account no. VERIFIED
Accepted and Approved

______________________ ______________________________
ICICI Bank Ltd.
Authorised Signatory
ICICI Bank Limited
 BANK’S COPY

KEY FACT STATEMENT AND MOST IMPORTANT INFORMATION

I/ We refer to final application form No. ................................. dated.................................. submitted by me/ us to ICICI
Bank Limited. I/ We have been provided the following information & have accordingly filled up the aforesaid.

Loan Details Rates and Charges

Loan Amount : 255500 Floating ROI p.a (Monthly Reducing Balance):..................................%

Tenure : Months NIL

* Processing Fees(Non Refundable)...............% NIL
Amount .......................

Number of EMIs 60 *Penalty for Delayed Repayment : 24% PA of overdue (2% per month)+GST
**EMI Amount *Cheque Bounce Charges : 500 +GST

*Auto Debit Bounce Charges : 500+GST

EMI Start Date 5th Day of Each Month

*Repayment Mode Swap Charges: 500(per transaction)+GST
EMI Due Date................................Day of each Month Prepayment / Preclosure Statement Charges : NIL

No. of Advance Installments...................................... Duplicate No Objection Certificate/ No Dues Certificate

Moratorium Period Charges : 250/- per NOC plus GST/ 250/- per NDC + GST

Revalidation of No Objection Certificate: 250/- per NOC plus GST

Date on which Annual Outstanding Balance CIBIL charges: 50 +GST

Statement will be issued: On Request EMI Bounce Charges: 500+GST
.
Repayment Mode Document Retrieval Charges: 500/-

Direct Debit Mandate

Statement of Account charges: NIL | Amortization Schedule charges: NIL
Schedule Adjustment charges/Part payment charges: NIL

ICICI BANK LIMITED

Name of Bank :......................................................................................................................................................................................................
1. *Plus Applicable Taxes and other Statutory Levies if any.
2. The security mandate collected would be sent to your bank for registration. Please note that the security mandate shall
be banked only in case of default in your loan repayment.
3. All cheques issued should be in favour of ICICI Bank Ltd. for Loan A/c of <full name of first applicant>.
4. EMI amount may vary basis disbursement date and date of first EMI. Rate of interest to remain the same.

I/We acknowledge that:

I/We have not made any payment in cash, bearer cheque or kind along with or in connection with this application to the executive collecting my/our
application form

The sanction under the Facility, if and when sanctioned, shall be governed by the terms and conditions applicable there to and it
shall be my/our responsibility to obtain the copy and read the same

ICICI Bank follows defined installment dates. Accounting reconciliation would be suitably depicted at the time of payment of last EMI and surplus amount,
if any, would be refunded to the applicant

Please read carefully before signing Date D D / MM / Y Y Y Y

I hereby confirm that I have received a copy of duly filled Key Fact Statement & Most Important Information as above.
Name of Applicant ..........................................................

Signature

Location:...........................................................
Signature:...........................................................Phone No................................................................ Stamp.................................................................
 CUSTOMER’S COPY

KEY FACT STATEMENT AND MOST IMPORTANT INFORMATION

I/ We refer to final application form No. ................................. dated.................................. submitted by me/ us to ICICI
Bank Limited. I/ We have been provided the following information & have accordingly filled up the aforesaid.

Loan Details Rates and Charges

Loan Amount : 255500 Floating ROI p.a (Monthly Reducing Balance):..................................%

Tenure : Months NIL

* Processing Fees(Non Refundable)...............% NIL
Amount .......................

Number of EMIs 60 *Penalty for Delayed Repayment : 24% PA of overdue (2% per month)+GST
**EMI Amount *Cheque Bounce Charges : 500 +GST

*Auto Debit Bounce Charges : 500+GST

EMI Start Date 5th Day of Each Month

*Repayment Mode Swap Charges: 500(per transaction)+GST
EMI Due Date................................Day of each Month Prepayment / Preclosure Statement Charges : NIL

No. of Advance Installments...................................... Duplicate No Objection Certificate/ No Dues Certificate

Moratorium Period Charges : 250/- per NOC plus GST/ 250/- per NDC + GST

Revalidation of No Objection Certificate: 250/- per NOC plus GST

Date on which Annual Outstanding Balance CIBIL charges: 50 +GST

Statement will be issued: On Request EMI Bounce Charges: 500+GST
.
Repayment Mode Document Retrieval Charges: 500/-

Direct Debit Mandate

Statement of Account charges: NIL | Amortization Schedule charges: NIL
Schedule Adjustment charges/Part payment charges: NIL

ICICI BANK LIMITED

Name of Bank :......................................................................................................................................................................................................
1. *Plus Applicable Taxes and other Statutory Levies if any.
2. The security mandate collected would be sent to your bank for registration. Please note that the security mandate shall
be banked only in case of default in your loan repayment.
3. All cheques issued should be in favour of ICICI Bank Ltd. for Loan A/c of <full name of first applicant>.
4. EMI amount may vary basis disbursement date and date of first EMI. Rate of interest to remain the same.

I/We acknowledge that:

I/We have not made any payment in cash, bearer cheque or kind along with or in connection with this application to the executive collecting my/our
application form

The sanction under the Facility, if and when sanctioned, shall be governed by the terms and conditions applicable there to and it
shall be my/our responsibility to obtain the copy and read the same

ICICI Bank follows defined installment dates. Accounting reconciliation would be suitably depicted at the time of payment of last EMI and surplus amount,
if any, would be refunded to the applicant

Please read carefully before signing Date D D / MM / Y Y Y Y

I hereby confirm that I have received a copy of duly filled Key Fact Statement & Most Important Information as above.
Name of Applicant ..........................................................

Signature

Location:...........................................................
Signature:...........................................................Phone No................................................................ Stamp.................................................................
 Demand Promissory Note

Rs. 2 5 5 5 0 0 Date: Place:

On demand, I/we the following

No. Name Age Son/Daughter/Wife of Residing at

1
2
3
4

jointly and severally promise to pay ICICI Bank Limited or order at their office situated at Mumbai, notwithstanding non-presentment, the sum
of Rs. 2 5 5 5 0 0 (Rupees_Two Lakhs Fifty Five thousand and Five Hundred only.) together with interest at the rate of per annum %
plus interest tax, with monthly rests, for value received
Authorised Signatories

Personal (full) Signature Signature over revenue stamp

1.

2.

Declaration for Existing & Past Credit Facilities

Date
TO
ICICI Bank Limited.,

Branch City

Reference: Loan Application No. dated under the Education Loan .

Dear Sir,

I/We hereby declare that I/We have availed financial facilities from various banks / financial institution. The details of the said facilities are as
below:

Name of the Name of the Bank

Applicant/Family and Financial Facility Availed Facility Amount Current Balance
Member Institution

Thanking you
Yours faithfully

Name (Applicant):

Signature ____________________________
 ANNEXURE
DEAL ORIGINATORS'CERTIFICATE (SIGNATURE VERIFICATION & IDENTITY PROOF TO BE ATESTED BY DEAL ORIGINATOR)

STATEMENT
I / WE CERTIFY THAT THIS
(Name of Applicant )
AGREEMENT HAS BEEN SIGNED BY ME IN THE PRSENCE OF
ICICI BANK LTD. ON. AT
(Designation)
(Date)
(address)

I / WE APPEND OUR SIGNATURE

(Name of Applicant)
(Signature of applicant)
1. I have satisfied myself with the identity of the applicant.
Signed /Counter-signed by Deal Originator Name of Deal Originators
*Where ICICI has appointed an AD,an employee of the AD must fill the undertaking form