AMERICAN EXPRESS INR CORPORATE CARD COMPANY ACCOUNT AMERICAN EXPRESS PAY BILL SERVICE FORM A

To: American Express Banking Corp. Cyber City, Tower C, DLF Bldg. No. 8, Sector- 25 DLF City Phase - II, Gurgaon - 122 002, Haryana Dear Sir, Re: Authorisation To Pay Corporate Card Bills Through The American Express Pay Bill Service 1. Name of Company: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Name of Corporate Cardmember: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Corporate Card Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D) 9 digit code number of the bank and branch appearing on the MICR cheque issued by the bank

(Please attach a cancelled blank cheque or its photocopy) E) Account type: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Saving/Current) with 10/11 F) Ledger Folio Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (If appearing on the cheque book) G) Account number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (As appearing on the cheque book)

4. Particulars of Companys Bank Account: A) Name of Account Holder: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B) Bank Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C) Branch Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................................................................

Yes, I have attached a cancelled blank cheque or its photocopy

Signature of Companys Authorised Signatory

Date

Signature of Corporate Cardmember

Date

FORM B
I hereby declare that the particulars given above are true and complete. If the transactions based on my above instructions are delayed, or are not effected for any reason whatsoCorporate Card to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of Cardmember) ever, I agree not to hold AEBC responsible for any loss /damage/inconvenience that may arise. I agree and understand that my bank shall be informed of this authorisation as per Bearing Card No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the enclosed letter. Also, I understand that the above instruction cannot be withdrawn/ I understand that Corporate Card means any Corporate Card issued by American cancelled except after due intimation and with the written consent of AEBC for the payment of Express that has the trade mark, or logo or service mark, or the name American Express the Card dues. either in conjunction with any other name or otherwise on the face of it. I, the undersigned, declare that at our request American Express has issued a I wish to avail of the American Express Bill Pay Service and hereby express my unconditional consent to debit payment of the above mentioned Card Account (or of any replacement/renewal Card that may be issued on the Card Account in lieu thereof) through participation in the Electronic Clearing System (ECS) of the National Clearing Cell of The Reserve Bank of India. I also unconditionally and irrevocably authorise American Express Banking Corp. (AEBC) to raise debits for such regular payments against our Bank Account Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . with . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Bank Name)

Signature of Companys Authorised Signatory

Date

Signature of Corporate Cardmember Note : Please complete in all respects

Date

!
I wish to avail of the Electronic Clearing System offered by the Reserve Bank of India towards settlement of the monthly Corporate Card bills. I have a Bank Account having Account Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . with your Bank. I hereby authorise you to debit to my above-mentioned account towards the above mentioned Corporate Card as raised by American Express Banking Corp. (AEBC). I further request you to inform AEBC of any change in the status of my account. In case I wish to revoke the above authorisation for any reason whatsoever, I undertake to inform AEBC the same in writing.

FORM C
To: The Manager (Bank Name) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bank Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................ ........................................................................ ........................................................................ Dear Sir, I, the undersigned, declare that at our request American Express has issued a Corporate Card to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of Cardmember) Bearing Card No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature of Corporate Cardmember Date Signature of Companys Authorised Signatory Date

* Please ensure that a cancelled blank cheque or its photocopy is attached

ELECTRONIC CLEARING SERVICE (DEBT CLEARING)/Direct Debit MANDATE FORM FOR BANK
SUBSCRIBERS AUTO DEBIT INSTRUCTION FOR SUBSCRIPTION PAYMENT

The Manager Bank Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Branch Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bank Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................. ............................................................................. Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sr. No.

I hereby authorise you to debit my bank account for making subscription payment to American Express Corp. through ECS (Debit) clearing as per the details given as under:

PARTICULARS OF MY BANK ACCOUNT

(Account Holder name should be as mentioned in Bank Account/Statement Account Holder Name: 9 digit code number of the bank and branch appearing on the micr cheque issued by the bank
(Please attach the photocopy of a cheque or a blank cancelled cheque issued by your bank for verifying the accuracy of the code number)

Account type: Ledger Folio Number:

Saving

Current
(to be written if applicable)

Account Number:
(As appearing on the cheque book)

Debit Frequency: Start Date:

As per invoice or intimation 2 0 End Date: 3 1 1 2 2 9 9 9

ACCEPTANCE, VERIFICATION AND CERTIFICATION

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 hereby unconditionally and irrevocably authorise American Express Banking Corp. to raise debits on such regular payments as referred to above mentioned bank account. Please debit the Mandate Verification Charges to my account mentioned above.

Date

Certified that the particulars furnished above are correct as per our records.

(Signature with stamp of any of the PAYER / SUBSCRIBER)

Bank Stamp: Place:

(Signature of the Authorised / Official from the Bank)