e/; izns'k xzkeh.

k cSad
Madhya Pradesh Gramin Bank
(Joint Venture of Govt. India, M.P. Govt. & Bank of India)

llTR!IT/Branch .............................................
fuR;r � JrR:r �ecl�e (RTGS) m �� �cl�Piqj � � (NEFT) � � �
Real Time Gross Settlement (RTGS) / National Electronic Fund Transfer (NEFT) Application Form
(Application Form to accompany with a cheque)
To,
Branch Manager, Madhya Pradesh Gramin Bank,
Branch ..............................................
� � � cf>T � (REMITTER DETAILS) /Date............................
;:i-rq
Name
� cf>T f<I> � � ffl'ffi w.
Account No. with Bank
Q"ffi
Address
�cat�T�.
Amount of Cheaque
�� ��
Cheaque No. Cheque Date
� cf>T � (BENEFICIARY DETAILS)
� cf>T ffl'ffi w.
Beneficiary Account No.
;:i-rq ( � � 4>tt1e<-1 � q)
Name (In Capital Letter)
� cf>T Q"ffi
Beneficiary Address

IFSC/RTGS Code
� cf>T f<I> q �Tiffi
I I I I I I I I I
Beneficiary's Bank & Branch
���.(�T«rrq)
Amount of Remittance (In Words)
( 1.) � /me/; izns'k xzkeh.k cSad clJ1"'3mfctcRur� 3ITT:TR� RTGS/NEFT-<i�c:l61x m�� ��� / ffl6 I
(2.) �/��6TTPRTGS/NEFT-<i�c:l61x ftl:rcf�tn fc1�lll-1'i q ����TT��61 ( 3.) � /m � clJl" �
��/ffl6°TTP� '3m •{i�c:l61x
� �lll-lljfilx RTGS/NEFT WTTxcfcl7xA�'3m�clJl"�� I ( 4.) � / m���j
ffl6TTP�/WITT"IDxT� � fctcRur i:rufc:r: fi"6t 6" a2TT� / wm-
IDxT � � � � fctcRur� 3ITT:1R � � ti�c:l61x
� �e/; izns'k xzkeh.k cSad co'l­ clJl"� \J"JqIisl�i:\1 .-fITT � I
(1.) I/We hereby authorize Madhya Pradesh Gram in Bank to carry out the RTGS/NEFTtransation as per the above detail. (2.)
I/We understand that the RTGS / NEFTtransaction is subject to RBI regulation and guidelines. (3.) I/We authorize the Bank to debit my
above account for the RTGS / NEFTcharges and taxes as applicable from time to time. ( 4.) I/We hereby declare that the above detail
given by us is correct and we acknowledge that Madhya Pradesh Gram in Bank accepts no liability for any consequences
arising out of erroneous details provided by me/us.)
( �$�������TT q � 'lffi'IT!IR ?f; fflll � ��lf !R't1T 'llR) Signature �aN/
Signatures if individual, Seal with signature if Properietor and Seal with signature of Authorized Signatories if Company

����I For Bank Use Only

Temp. Transaction No. SNM ......................................................
Transaction No. SNM.................................................................. x-1,<-11 fqa cpaf � � ��
UTR. No. BK.ID .......................................................................... Signature of Verifying Officers