Customer Request Form - Axis Bank 41163x

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CUSTOMER REQUEST FORM

For Branch Office Use Only (Encircle Requested SR/s)

Please strike off the fields which are not applicable

The Branch Head Axis Bank Ltd.

BANK

Branch | 5ol lD:

Date of Request:

Customer Name: Number:

Customer ld:

1.

MoBILE NUMBER UPDATE/REGISTRATION

:

Avail following Services - Transaction Alerts (Tick on the "Subscribe" Option Below), Get Balance & Last 3 txns through SMS, financial txns on internet banking, Duplicate Debit Card/ Pin Request.

ALERTS:

|

|

| Subscribe

2.

| Unsubscribe

(Only Mandatory Alerts will be sent. For e.g. All card based & Internet Banking transa(

(All alerts will be sent. Charges applicable @Rs S/month)

LANDLINE NUMBER UPDATE (Res): LANDLINE NUMBER UPDATE (Off):

3.

EMAIL ID (FOR E-STATEMENT REGISTRAT1ON): ln case E-Statements are activated, physical statements will be disabled

4.

PERMANENT NUMBER (PAN) DETAILS:

5.

AADHAR NUMBER

6.

CHANGE OF MAILING ADDRESS (ln case of

:

t holders, each holder needs to fill

Landm'arkr:

STATE*

a separate

form)

:

Pin Coder:

City*: DOCUMENT FOR PROOF OF ADDRESS (Mandatory for change in Mailing Address): DOCUMENT IDENTIFICATION NUMBER: PLACE OF ISSUE:

ISSUING AUTHORITY: VALID TILL

ISSUE DATE

7.

NEW CHEQUE BOOK REQUEST: Number of Cheque Book/s Required:

8.

ACTIVATION: PLEASE REACTIVATE MY NUMBER REASON FOR NOT OPERATING THE :

9.

OTHERS

I have read, understood and agree tothe and conditionsto various products and seruices including SMS Banking, E-Statement and lnternet Banking. I accept and agree to be bounded bythe and Conditions as displayed on ww.axisbank.coBl agreethat the bank may debit service charges plustaxesto my wherever applicable.

CUSTOMER SIGNATURE:

PLACE:'

DATE:

FOR BRANCH OFFICE USE ONLY Certi{ied that this Request Letter is complete in all respect & all relevant documents are obtained & verifieil mode of operation and signatures ofthe Vc. request may please be processed.

|

|

BANK TNDUCED

lhe

REg FORWARDEDTO CLH DATE:

REQUEST RECEIVED DATE: REQUEST ACCEPTED BY:

EMPLOYEE

NUIVIBER: Designation:

Request Certified By Signature r.aaaaarlartrrrr-llaaaar.aartrrrrtrr.artaaaaarattr....raaaaaaDrttttr]ar.alrratDt

<,IGNATURE:

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ACKNOWLEDGEMENT TO CUSTOMER Customer Name: Date of Request Received: Name of Branch Official:

-

Sigiature:

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AXIS BANK CUSTOMER REqUEST FORM Please strike off the fields which are not applicable

10.

DUPTICATESTATEMENT

Statement Required From Date:

To Date;

11. DEBIT CARD

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oF DEBtr cARD NUMBER:

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oF CARD NUMBER:

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rssuE DEBrr cARD DUPLIcATE PtN

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STOP PAYMENTREQUEST

Number of Cheques:

EU

Payees Name:

Or aO 6u

Cheque Number(s):

tr

Date of Cheque:

Reason for Stop Payment:

Amount:

13.

REVERSATOFCHARGES

Amount of Debit:

Date of Debit:

I undertake to keep henceforth an Average Monthly

/

Quarterly

/

Rs

Half Yearly Balance of Rs. (ln case of Average Balance

Non-Maintenance Charges only):

14.

[

ssuANcEoF BooK

rs.

I

srGNAruRE vERrFrcATroN

16.

ANY OTHER (Please Specify)

I have read, understood and agree to fhe and conditions to various products and services. I accept and agree to

be

bounded by the and Conditions as displayed on www.axisbank.com. I agree that the bank may debit service charges plus taxes to my wherever applicable. DATE:

PIACE:

CUSTOMER SIGNATURE:

FOR BRANCH OFFICE USE ONTY

Certified that this Request Letter is complete

in all respect & all relevant documents are obtained & verified mode of operation

and

signatures of the A/c. The request may please be processed.

I I BANK TNDUCED REQUEST REQUEST RECEIVED DATE: REQUEST ACCEPTED BY:

Request Certified By Signature

FORWARDED TO CLH DATE: EMPLOYEE NUMBER:

Desisnarion:[]

o,

ACKNOWTEDGEMENT TO CUSTOMER Customer Name: Date of Request Received: Name of Branch Official:

Signature:

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