Application for National Electronic Fund Transfer/

Real-Time Gross Settlement Systems (NEFT/RTGS)

AAXIS BANK
To,
The Branch Manager

Date I .I
PAN I I I
Deor Sir,
Branch
•To be provided by Axis Bank customer
Please remit through NEf!/RTGS a sum of °'--'--- ----(Rupees In words)---------------------:-
---------------------------------------------- only
as per details given below:

Ocash . DCheque DDebit my/our account

•in case of cash, please fill in the pay-in-slip

-To be filled by the Applicant in CAPITAL LETTERS

CD . DETAI LS OF APPLICANT (REMITTE R)

Account Number I I I
Cheque Number I I I Cheque Date Remitter's Name I II
I I I
Address I I I
Mobile I Other Number I I I
DETAI LS OF BENEFICIARY

Beneficiary's Name I I
I I I
Account Number I·I I
Reconfirm Account Number t I I
Bonk Name I I r
IFSC Code (11-digit) r I I l

Branch Address I I I I ., ·I
Sender to Receiver information (if any):

TERMS AND CONDITIONS

This trander is valid for a single transaction .
The fund trnsfer Will be governed by the Terms ond Conditions given on our website www.axisbank.com
•• Due care is taken while filling up the beneficiary account number & IFSC code
Trnsfer of an amount up 49,999 in cash permissible using this facility . Photo ID proof to be given by non customer for cash poyment above---------
Pleose do not disclose your Account details/Internet Banking, User ID and Passwords/ATM debit Card/Credit Card/Mobile Banking/Personal Information to any person
Do not fall prey to false promises; beware of dubious scheme

0 DECLARATION
l/INe authorise Axis Bank lo recover charges as may be applicable by debiting my account as mentioned above .
l/INe understand that as per the RBI Circular doted October 14, 2010, transfer of funds through electronic mode will be executed only on the basis of the account number of th
I understand that this facility is available only al select locattions and banks covered under Electronic Funds Transfer fo.:ility offered by RBI
CUSTOME R SIGNATURE(S)
Sianature
S1gnaturn
'>1<J nc1t1,r
Nome
•(Pri""!ary Applicant)

II II
Name Nom e

•(Joint Applicant l ) •(Joint Applicant 2)

(. ,. ,

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Date l o l o l M l ,,, l v l ( i • l r l

We anowledge receipt of NEFT I RTGS instruction(s). Reference no. .

Branch Nome and Signature of Bonk Official With Date & Time
Remitter's Name Account No.-----------Cheque No.-------
of Request

Benefic:iory Nome Account No. IFSC Code--------

Amount (In figures) Amount (In Words), _
nt number of the beneficiary provided while initialing'the tronsodion. Nome will NOT be considered as a criteria for providing credit

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