ELECTRONIC CLEARING SERVICE (CREDIT CLEARING)

MANDATE FORM

Scheme Name : Electronic Clearing system for Payment

1. Name of the Account Holder (should be : THE PRINCIPAL-CHENNAI INSTITUTE
“The Principal” only) OF TECHNOLOGY AND APPLIED
RESEARCH
College Code (TNEA Counselling Code) : 1398

Name and Address of the Institution : CHENNAI INSTITUTE OF TECHNOLOGY

AND APPLIED RESEARCH,
SARATHY NAGAR,
KUNDRATHUR,CHENNAI-600069
2. Particulars of Bank Account :
A. BANK NAME : AXIS BANK
B. BRANCH NAME : MOULIVAKKAM BRANCH
BANK ADDRESS : MOULIVAKKAM,CHENNAI-600125
BANK TELEPHONE NO. : +91 9876543210

C. Account Number (As appearing on

the Cheque Book) 923020040549909

D: 9 Digit code number of the bank and :

Branch appearing on the MICR 600211082
Cheque issued by the Bank

E. Bank’s IFSC code : UTIB0003094

F. Account type (S.B. Account / Current :
Account of Cash Credit) with Code SAVINGS ACCOUNT
10/11/13

G. Ledger No. / Ledger Folio No. : -

Note: Please attach a blank cancelled cheque or photocopy of a cheque and front page of
your savings bank pass book issued by your bank for verification of the above particulars)
3. DATE OF EFFECT : 24.11.2023

I hereby, declare that the particulars given above are correct and complete. If the
transaction is delayed or not effected at all for reasons of incomplete or incorrect information.
I would not hold the user institution responsible. I have read the instructions and agree to
discharge the responsibility expected of me as a participant under the scheme.

Signature of the Principal with Seal Signature of the Chairman with Seal
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FOR BANK USE ONLY
Certified that the particulars furnished above are correct as per our records.

BANK’S STAMP Signature of the Authorized / Official

from the Bank