Application for National Electronic Fund Transfer/ Real-Time Gross

To, Settlement Systems (NEFT/RTGS)

Immediate payment Service (IMPS)
The Branch Head
                            Branch I I I I j Iv I j I
Dote O O
M 1
• Y 1

PAWi I  I I  I  I  I  I  I  I
Dear Sir,

'lobeprovided by Axis Bonk customer

Plecise remit through NEFT/RTGS/IMPSo sum                                          Rupees In words),                                  .;.                               

                                                                                                                                                                           only, as per details given below:

D Cash• (Only for NEFT Transactions upto 49999/-) D Cheque D Debit my/our account
'In cose of cosh, please fill in the poy-in-sr.p •cosh only for NEFT pee doy
'To be fllled by the Applicant In CAPITAL LETTERS •1MPS limit fo 2 .00 Lokhs-0nly
Account Number I I I I ICheque Number I I I I I ChequeDote IOID IMI "'IY Iv vIvI

DETAILS OF  APPLICANT (REMITTER)
DETAILS OF  BENEFICIARY
TERMS AND CONDITIONS
DECLARATION
CUSTOMER SIGNATURE(S)

-                                                  
ACKNOWLEDGEMENT TO CUSTOMER
Oote:l1.. . ._,._...,             ,                ._,._......_--'

We acknowledge receipt of NEFT / RTGS/!MPSinstruction{s).

Reference No(For RTGS/NEFT] Retrieval Reference No {For IMPS)                                                           For Sokshom Reference No (For IMPS)
Branch.                                       Nome ond Signature of Bonk Official                                                                                                     Wrth Dote & Time Request
RemiNer's Nome                                                                      A<:count N_o ..                                                                          Cheque No..                                                                             
Beneficiary Nomo Account No. IFSC.                                                                                   _
Amount in figures Amount (In Wor_ds)                                                                                                                                                              _
 "AXIS BANK

eI I I I j Iv I j I
O O
M 1
• Y 1

AWi I  I I  I  I  I  I  I  I
provided by Axis Bonk customer

                             .;.                               
            only, as per details given below:

ount
hequeDote IOID IMI "'IY Iv v I v IRemitter's Nome I l IIIIIIII [ II IIIIIIIII I lAddress
   

kshom Reference No (For IMPS)

h Dote & Time Request
                                                              
                                                _
                                                    _