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APPLICATION FOR PAYMENT ORDER (‡c-AW©vi Bm¨iy Av‡e`b)

Date (ZvwiL): ____________________

Branch Manager (kvLv e¨ve¯’vcK)


The City Bank Ltd. (w` wmwU e¨vsK wjwg‡UW)
Branch (kvLv): ____________________

Dear Sir/Madam (wcÖq g‡nv`q),

Please issue Payment Order as under (AbyMÖn K‡i wb¤oeewY©Z †c-AW©viwU Bm¨y Kiæb):
 I/we tender herewith cash Tk (bM` Rgv) ....... ....... ....... ....... ....... ....... .......
 I/we enclosed cheque no. (Avwg /Avgiv mshy³ Kijvg †PK bs)............ ............ .............. Dated (ZvwiL) ......................................... ......
 Please debit my account no. ……………........................................ maintained with yourselves for Tk ......................................
Commission…………….…... VAT………….….. Total…….…………….…… along with all necessary charges. (AbyMnÖ K‡i Avgvi GKvD›U n‡Z
‡c-AW©v†ii g~j¨ mn avh©¨K…Z PvR©/PvR©mg~n eve` UvKv †WweU Kiyb)
Beneficiary Bank &
Amount Commission VAT
Beneficiary(cªvcK) Branch Detail (cÖvcK e¨vsK
(cwigvY) (কwমশন) (ভ¨vট)
Ges kvLvi weeiY)

Total (‡gvU)
Total local currency in words Tk. (‡gvU UvKvi cwigvY, K_vq) ___________________________________________________________
The Pay Order(s) will be collected by me/authorized representative (signature attested). (‡c-AW©viwU Avwg/Avgvi Aby‡gvw`Z
cÖwZwbwa Øviv D‡Ëvjb Kiv n‡e| ¯^vv¶i mZ¨vwqZ)

Signature of the Representative


cÖwZwbwai ¯^vv¶i
Attested (mZ¨vwqZ)

______________________ ________________________
Signature of 1st Applicant Signature of Joint Applicant
(cª_g Av‡e`bKvixi ¯^vv¶i) (hyM¥ Av‡e`bKvixi ¯^vv¶i)

FOR BANK USE ONLY Customer ID: C B

CHECK POINTS
[

Transaction ID:________________________________

We the undersigned confirm that all the related document(s) are in order as per CBL Ops Manual/SOP/related circulars and all
necessary approval(s) are taken.

Initiated By CS Official/CFP Recommended by BOM/Designated Approved by BM/Designated


(with seal & sign) Official (with seal & sign) Official (with seal & sign)

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