Customer Request Form

Date: / /

To: Auto & Smart Loan Service Desk Unit

Customer Name:………………………………………………………….

Customer ID / Loan Account number- …………………………… Customer Tel No:…………………………………

Customer Mobile No: 050-……………………………………

 I/we would like to pay cash amount of AED…………………………- being the charges.

 Please debit my / our account……………………..……….with charges of AED………………..…… for the services selected below.

Please tick the appropriate request given below

 Replacement of post-dated cheques Request for Release Letter/ Clearance Letter

 Settlement of loan before maturity Change in repayment mode
 NOC for change in registration  Retrieval of post-dated cheques
 NOC to take car out of UAE  charges reversal/ Refund
 Liability Letter - Total Loss  Advance Payment of EMI
Others  Retrieval of security cheques
 Collecting balance PDC’s post loan settlement

Others: …………………………………………………………………………………………

Documents Attached - ……………………………………………………………………………..

I/we acknowledge that the Bank reserves the right to approve or decline my/our service request at its sole discretion, and as per the Bank’s current policy in
effect further documentation (i.e. Bank statements, salary certificate, etc) may need to be presented by me/us in order to process the request
I/we acknowledge that the Bank will levy a service fee in order to process the above service request at its sole discretion.
I/we hereby declare that the above information provided is true and correct.
I/we authorize ADCB to verify this information from within the Bank’s records and acknowledge that I/we remain liable for all amounts due to the Bank under
the above-mentioned facility/facilities and for any related charges pertaining to the facility/facilities as described in my/our loan contract(s) which I/we have
signed during loan inception.
Note: In case the customer wishes to retrieve the balance post-dated cheques and / or security cheques upon settlement of loan before maturity / change of
repayment mode, the customer/s must request for the same within fifteen (15) days of settlement of loan / change of repayment mode. Beyond fifteen days of
loan settlement, ADCB shall have the authority, at its discretion, to destroy the balance post dated cheques including security cheques (if any) without any
further notice to the customer/s.

Customer Signature

For Bank Use Only

Branch / Office: …………………..

Staff Name: ……………………....

Staff Number: …………………... Staff Signature: ………………………………….