Declaration on letter head of the firm

Bar Code ____________________________________

Date:

To,
ICICI Bank Ltd,
________________Branch

Dear Sir/Madam,
Ref: Account Name ________________________________________________________

Note: Please tick applicable declarations

Declaration for opening Proprietorship account with Single entity proof) (Please tick if applicable)

I, _________________________________________ hereby declare that I am unable to submit two entity proofs as required for opening Proprietorship
current account as required by and as applicable as per ICICI Bank policy/process, since I do not have the required document in the name of my firm
presently, and hence am requesting you to open my account with a single entity proof / KYC document.

I undertake that I was given the complete list of documents that are accepted as KYC documents for opening the Proprietorship account.

Declaration for Recording different Signatures (Please tick if applicable)

With reference to my <document> bearing reference number <documentnumber> and the account opening form
I have submitted here with, I request you to record with yourselves my specimen signature as below:

_____________________________

While the signature recorded in the <document> is different. This difference in signature is because___________________________________.

Declaration for Cheque from Savings account for Firm with vintage > 1 year (Please tick if applicable)

I confirm that I do not hold current account in any of the banks, hence I am providing cheque from my Savings account
Declaration for Name Variation permissible within ICICI Bank guidelines (tick if applicable)

I/We request you to register my/our name as___________________________________ in your record.

As per the furnished document/s, (i)____________________________, (ii)__________________________ and (iii)________________________________

my/our name is/are (i)______________________, (ii)_____________________ and (iii)______________________ respectively.

I/We do hereby solemnly affirm and state that my correct name is _________________________________

Declaration for Name Variation permissible within ICICI Bank guidelines (Please tick if applicable)

I/We request you to register my/our name as___________________________________ in your record.

As per the furnished document/s, (i)____________________________, (ii)__________________________ and (iii)________________________________
my/our name is/are (i)______________________, (ii)_____________________ and (iii)______________________ respectively.
I/We do hereby solemnly affirm and state that my correct name is _________________________________.

ü I confirm that my details and signature provided above are true and updated
ü I/we undertake to not hold ICICI Bank or any of its officials/directors responsible for any direct, indirect, consequen al liability / claims / loss suffered by
me/us, due to ICICI Bank undertaking any of the aforemen oned ac ons.

Place:_______________________ ______________________ ______________________

(Signature of applicant/authorized signatory with stamp)

I confirm that the customer has signed in my presence:

Signature of the bank official: _______________________

Name of the bank official: __________________________

Employee Number : _______________________________