BL00

BUSINESS INSTALMENT LOAN Sourcing Channel

APPLICATION FORM Branches
Business Instalment Loan DSA
Doctor Program Alternate
This form will also be used to source Business Credit Card
*Please select: MUDRA NON MUDRA
PSL
FOR BANK USE ONLY

SOL ID RM Name Employee No. Date

Channel Name Executive Name Executive Code
DSA Code VSTS Code Ref by (Emp PB/VB/Salary)
Customer Code Surrogate Code Promo Code CRM ID
CCID Code CRN Code 4th Line Logo

Application Type: New Update | KYC Number (Mandatory for KYC update request)

Account Type: Normal Simplified (for low risk customers)

Disbursement Facility for Professionals/ Doctors: BL Term Loan BL Over Draft

PRELIMINARY CREDIT FACILITY APPLICATION FROM

DETAILS OF THE APPLICANT (Non Individual) Applicable only for the applicant (not for Co-applicant / Guarantor)

Business Entity Details

Business Constitution Prop. Concern Pship. Firm Pvt. Ltd. Co. Public Ltd. Co. Society Trust HUF Others_________
Nature of Business Trading Manufacturing Export / Import Services Others __________
Name of Business/ Entity
GST Compliant Yes No If Yes, GST No.
Industry/ Sector/ Activity
ZED rated Yes No If Yes, Gradation: Bronze Silver Gold Diamond Platinum
Current Office Address

City Pin
Telephone(O) - Fax Office Type Owned Rented
E-mail ID PAN
Date of Incorporation
Additional Office Address
(Factory/ Shop/ Branch)
City Pin
Telephone(O) - Fax
Preferred Mailing Address EMAIL/SMS Alerts Residence Office
For Business Credit Cards ICICI BANK GOLD BUSINESS CARD (Tick only if you wish to avail) Joining Fee: Nil Annual Fee: Nil

COMPANY PROFILE

Name of the Company as you would like it to appear on the Card (Maximum 19 characters):
Mailing Address :

Registered Address :
No. of Employees:
If subsidiary/branch, name of the Parent Company
Existing relationship with ICICI Bank Yes No If Yes, please specify :
 PERSONAL DETAILS (INDIVIDUALS)

Title Mr. Mrs. Miss M/S Others_________ APPLICANT CO-APPLICANT GUARANTOR

Name
Maiden Name
Spouse Name
Father's Name
Mother's Name
Date of birth Spouse DOB Gender: Male Female Transgender
Education Post Graduate Professional Diploma Graduate Under Graduate/Matric.| Religion
Customer Category General SC ST OBC Other _________________ Marital Status: Married Single Others ____________
Residence Address

City/Town/Village District
Nearest Landmark
State Code PIN Tel ( R ) -
Residence is Self Owned Rented (Monthly rent ______________) Company provided Other __________________
Residence Type Bunglow(B) Row House(R ) Flat(F) Other(O) __________________
No. of years at above residence Yrs Months Tick, if Permanent Address is same as the Residence Address
Permanent Address

City/Town/Village District
Landmark State code PIN
Tel ( R ) - Location Category Rural Semi Urban Urban Metro
Additional Address
District
City/Town/Village State code PIN
Nearest Landmark Tel( R ) -

Mobile No. Email ID

No. of Dependents Alternate Email ID
Gross Income (per annum) UID No.
Citizenship IN-Indian Others (ISO 3166 Country Code)
Residential Status Resident Individual Non-resident Individual Person of Indian Origin Foreign National
Occupational Details
Business Trading Manufacturing Export / Import Services Others ___________________
Self Employed Professional CA Doctor Engineer Architect/ Interior Decorator Others ___________________

For Business Credit Cards

Name to be Printed on Card (Maximum 19 characters)

Existing ICICI Bank Credit Card Member: Yes No If yes please specify :
PROOF OF IDENTITY(POI) (Certified copy of any one of the following POI needs to be submitted)
A - Passport Number Expiry Date
B - Voter ID Card
C - PAN Card
D - Driving License Expiry Date
E - UID( Aadhar) or VID No.
F - NREGA Job Card
Z - Other( any docment notified by government) Identification No.
S - Simplified Measures Account - Document Type Code Identification No.
PROOF OF ADDRESS (POA) Current/ Permanent/ Overseas Address Details (Certified copy of any one of the following POA needs to be submitted)
Address Type Residential / Business Residential Business Registered Office Unspecified
Proof of Address Passport Driving License UID(Aadhar) Voter ID card NREGA Job Card Other
Simplified Measures account- Document Type Code
Current address (correspondence / local address): State/ UT code: ISO 3166 Country Code
Permanent Address: State/ UT code: ISO 3166 Country code: Overseas Address: ISO 3166 Country code
 PERSONAL DETAILS (INDIVIDUALS)

Title Mr. Mrs. Miss M/S Others_________ APPLICANT CO-APPLICANT GUARANTOR

Name
Maiden Name
Spouse Name
Father's Name
Mother's Name
Date of birth Spouse DOB Gender: Male Female Transgender
Education Post Graduate Professional Diploma Graduate Under Graduate/Matric.| Religion:
Customer Category General SC ST OBC Other _________________ Marital Status: Married Single Others ____________
Residence Address

City/Town/Village District
Nearest Landmark
State Code PIN Tel ( R ) -
Residence is Self Owned Rented (Monthly rent ______________) Company provided Other __________________
Residence Type Bunglow(B) Row House(R ) Flat(F) Other(O) __________________
No. of years at above residence Yrs Months Tick, if Permanent Address is same as the Residence Address
Permanent Address

City/Town/Village District
Landmark State code PIN
Tel ( R ) - E Location Category Rural Semi Urban Urban Metro
Additional Address
District
City/Town/Village State code PIN
Nearest Landmark Tel ( R ) -

Mobile No. Email ID

No. of Dependents Alternate Email ID
Gross Income (per annum) UID No.
Citizenship IN-Indian Others (ISO 3166 Country Code)
Residential Status Resident Individual Non-resident Individual Person of Indian Origin Foreign National
Occupational Details
Business Trading Manufacturing Export / Import Services Others ___________________
Self Employed Professional CA Doctor Engineer Architect/ Interior Decorator Others ___________________
PROOF OF IDENTITY(POI) (Certified copy of any one of the following POI needs to be submitted)

A - Passport Number Expiry Date

B - Voter ID Card
C - PAN Card
D - Driving License Expiry Date Y Y Y Y
E - UID( Aadhar) or VID No.
F - NREGA Job Card
Z - Other( any docment notified by government) Identification No.
S - Simplified Measures Account - Document Type Code Identification No.

PROOF OF ADDRESS (POA) Current/ Permanent/ Overseas Address Details (Certified copy of any one of the following POA needs to be submitted)

Address Type Residential / Business Residential Business Registered Office Unspecified

Proof of Address Passport Driving License UID(Aadhar) Voter ID card NREGA Job Card Other
Simplified Measures account- Document Type Code
Current address (correspondence / local address): State/ UT code: ISO 3166 Country Code
Permanent Address: State/ UT code: ISO 3166 Country code: Overseas Address: ISO 3166 Country code
DETAILS OF FACILITY REQUIRED*

Credit Facility Amount Tenure M M Months

Purpose of Facility Business Expansion Working Capital Purchase of Plant & Machinery Others____________________
*Subject to Approval

DETAILS OF PARTNERS / DIRECTORS OF FIRM / COMPANY & THEIR ADDRESSES

Academic Category: SC/ST/OBC
S.No Name Date of Birth Father/ Spouse Qualification Minority / Women Mobile No.

NAMES OF ASSOCIATE CONCERNS AND NATURE OF ASSOCIATION:

Name of Associate Concerns

Address of Associate Concerns

Presently Banking With

Nature of Association
Extent of Interest as a Prop.
Partner/ Director or Just Investor
in Associate Concern

EXISTING CREDIT FACILITIES (PLEASE INCLUDE ALL APPLICANTS OF THE LOAN)

Facility Type of Limit / Loan Outstanding Bank / EMI ROI Repayment Balance Securities
in favour of Facility (In Lakh) as on _____ Financier (in Rs.) (in %) Terms / Tenor Term Lodged
(In Lacs)

It is certified that our unit has not availed any loan from any other Bank/Financial Institution in the past and I am not indebted to any other Bank/Financial Institution
other than those mentioned in table above.

BANK ACCOUNT DETAILS

Name of Account Holder Bank / Branch Type of Account Account Number CC/OD Limit (in Lacs) Banking Since

UPI/VPA

PAST PERFORMANCE

Parameter (In Lakh) Past Year 1_______ (Actual) Past Year 2_______ (Actual) Present Year _______ (Estimate)

Net Sales

Net Profit
Capital (Net worth, if company)
 INSURANCE INDENT DECELERATION
I/We hereby declare that I/We would like to opt for insurance plan offered by insurance company in association with ICICI Bank. I/ We have carefully read and understood the contents
of brochure.
I/We have understood that the insurance premium shall be deducted from the loan amount sanctioned by ICICI Bank and I hereby authorize ICICI Bank to deduct the insurance
premium from sanctioned loan amount and disburse only the remaining loan amount.

I confirm that I am voluntarily participating in this programme and am aware that the loan is available without insurance as well
Signature of the Applicant

STATUS REGARDING STATUTORY OBLIGATION

Whether complied with, select Yes / No. If not applicable, select NA Remarks

1. Registration under Shop and Establishment Act Yes No NA

2. Industry Specific License Yes No NA
3. Latest GST Return Filed Yes No NA
4. Latest Income Tax Return Filed Yes No NA
5. Any other statutory dues remaining outstanding Yes No NA

KYC VERIFICATION CARRIED OUT BY

Emp. Name Emp. Designation

Emp. Code Emp. Branch

Date
Employee Signature

TRADE REFERENCE CHECK REPORT

Sr. No. Name of the Person Name of the Entity Relationship Address Mobile No.
1.

PIN
2.

PIN
Other Remarks:
Please note that references should not be taken from friends or relatives. References should be taken from Business Associates viz., Customers & Suppliers

AUTHORITY LETTER

AUTHORITY LETTER FOR MY ICICI BANK AC NO. :

I Mr/ Ms _______________________________________________ am authorising ICICI Bank Official to download the bank statement of my account number
as captioned from _________ 20____ to _________20____. I here by declare that the downloaded bank statement can be used as address proof in accordance
with your norms for Know Your Customer (KYC). I hereby take full responsibility for the bank statement and authorise ICICI Bank to use the same for KYC/ other
assessement purposes.

Date
Place ________________________ Signature (Applicant)

NOMINATION DETAILS FOR CREDIT CARD INSURANCE COVER

Name of the Nominee*

Date of Birth* D D M M Y Y Y Y Relationship With Card Applicant

PURPOSE OF THE LOAN*

Utilisation District Utilisation Taluka Occupation

Division . Sub Division Activity
PHOTOGRAPH AND SIGNATURES

Photograph of Photograph of
Primary Applicant Co- Applicant 1/Guarantor 1
Please Paste Recent Please Paste Recent
Passport - sized Passport - sized
Photograph and Photograph and
sign across it sign across it
Signature of Primary Applicant Signature

Co-Applicant 1 Guarantor 1

Name __________________________________________________ Name __________________________________________________

Place: _______________________________Date: ______________ Place: _______________________________Date: ______________

Photograph of Photograph of
Co- Applicant 2/Guarantor 2 Co- Applicant 3/Guarantor 3
Please Paste Recent Please Paste Recent
Passport - sized Passport - sized
Photograph and Photograph and
sign across it sign across it
Signature Signature

Co-Applicant 2 Guarantor 2 Co-Applicant 3 Guarantor 3

Name __________________________________________________ Name __________________________________________________

Place: _______________________________Date: ______________ Place: _______________________________Date: ______________

Note: Please ensure that you get the perforated acknowledgement copy duly filed in by our sales representative

DECLARATION BY AUTHORISED CORPORATE OFFICER SECTION

Title Mr. Ms Dr. Mx.

Name of the Authorised Signatory
Designation
Tel(Direct) S T D L A N D L I N E Tel(Board) L A N D L I N E Ext. No.
Email ID
Credit limit on the card or % of the total limit issued to the business
Mothers Name*
DECLARATION

COMMON DECLARATIONS – TERMS & CONDITIONS

1. I/We declare that all the particulars and information and details given/ filled in this application form are true, correct, complete and up-to-date in all respects and that I / We have not
withheld any information whatsoever.
2. I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case
any of the above information is found to be false or untrue or misleading or misrepresenting. I am aware that I may be held liable for it.
3. I hereby consent to receiving information from Central KYC Registry through SMS/ Email on the above registered number/email address.
4.I /We confirm that no insolvency proceedings or suits for recovery of outstanding dues or monies whatsoever and/or any criminal proceedings have been initiated and/or are pending
against me/us and that we have never been adjudicated insolvent by any court or other authority.
5.No action nor other steps have been taken or legal proceedings started by or against me/us in any court of law/other authorities for Winding up, dissolution, administration or
reorganization or for the appointment of a receiver, administrator, administrative receiver, trustee or similar officer or for my/our assets.
6.I/We declare that I/we have not made any payment in cash, bearer cheque or kind along with or in connection with this application to the executive collecting my/our application. I/We
shall not hold ICICI Bank liable for any such payment made by us to the executive collecting this application.
7.I/We understand and confirm that the Application Form and all other documents submitted by me/us to ICICI Bank shall not be returned to me/us and ICICI Bank shall have the right to
retain the same.
8.I/We authorize ICICI Bank Limited (ICICI Bank) and all its group companies and their agents to exchange, share or part with all the information and details relating to my/our existing
loans and/or repayment history to other ICICI group companies, banks, financial institutions, credit bureaus, agencies, statutory bodies etc. as may be required or as they may deem fit
and shall not hold ICICI Bank (or any of is group companies or its/their agents/representatives) liable for use/sharing of this information.
9. I/We understand and acknowledge that ICICI Bank shall have the absolute discretion, without assigning any reasons (unless required by applicable law), to reject our application and
that ICICI Bank shall not be responsible/ liable in any manner whatsoever to me/us for such rejection or any delay in notifying me/us of such rejection and any costs, losses, damages or
expenses, or other consequences, caused by reason of such rejection, or any delay in notifying me/us of such rejection, of our application.
10. Except to the extent disclosed to ICICI Bank , no director or a relative/near relation (as specified by RBI) of a director of a banking company (including ICICI Bank) or a relative/near
relation (as specified by RBI) of a senior officer of ICICI Bank (as specified by RBI) is: the Applicant (s), or a partner of our concern, or a trustee, member, director, manager, employee of
our concern, or of our subsidiary, or our holding company, or a guarantor on my/our behalf, or holds substantial interest in our concern or my/our subsidiary or holding company.
11. I/We hereby certify/authorise that all information furnished by me/us is true, correct and complete; that I/We have no borrowing arrangements for the unit except is in the application;
that there is no over dues/ statutory dues against me/us/promoters except as indicated in the application; that I/We have not been declared as defaulter/wilful defaulter by any Bank/FS
and no Legal action has been taken/initiated against me/us by any Bank/FIsI/We shall furnish all other information that may be required connection with my/our application that this
may also be exchanged by you with an agency you may deem fit and you, your representatives or Reserve Bank of India or any other agency as authorised by you, may at any time,
inspect/ verify my/our assessment of account etc. in our factory/business premises as given above; you may take appropriate safeguards/action for recovery of Bank's dues including
publication of defaulters name in website/submission to RBI; further agree that my/our loan shall be governed by the rules of your Bank which may be in force from time to time.
12. I / We hereby declare that I/We would like to opt for insurance plan offered by insurance company in association with ICICI Bank. I / We have carefully read and understood the
contents of brochure. I/We have understood that the insurance premium shall be deducted from the loan amount sanctioned by ICICI Bank and I hereby authorize ICICI Bank to
deduct the insurance premium from sanctioned loan amount and disburse only the remaining loan amount. Insurance is a subject matter of solicitation.
FOR BUSINESS CREDIT CARDS:
13.The Company/Firm hereby applies for establishing in the name of the Company/Firm an ICICI Bank VISA/MasterCard Business Card Account and agrees to accept and be bound by the
Terms and Conditions governing the Business Card facility prescribed by ICICI Bank in this regard from time to time. It is certified that the person signing this application form has full
authority to do so and thereby binds the Company/Firm to the Terms and Conditions governing the Business Card facility provided by ICICI Bank and the ICICI Bank Business Card
Account Terms and Conditions.
14.The Company/Firm declares and undertakes that the ICICI Bank Business Card issued to those persons named by the Company/Firm, if used overseas shall be utilized strictly in
accordance with the relevant exchange control regulations, issued and amended by the Reserve Bank of India from time to time. And in the event of any failure to do so by any of the
persons named by the Company/Firm, the said person shall be liable to, for any action under the Foreign Exchange Management Act, 1999 as amended from time to time or any
corresponding Act/applicable law and that person shall be debarred from the Business Card Facility either at ICICI Bank’s instance or by RBI. The Company/Firm also agrees that its
cardholders will comply with all Foreign Exchange rules and regulations in force at present and also any additions / amendments made there to from time to time by the Reserve Bank o
India.
15.The liabilities of the Card member and the Company/Firm are as per the conditions set out in the Terms and Conditions governing the Business Card. By executing this Application form,
the Company/Firm agrees to abide by the terms contained in this application form, the Most Important Terms and Conditions and the Terms and Conditions governing the Business Card
facility of ICICI Bank Limited. The Company agrees that access to any changes/updation in the Terms and Conditions applicable to the Business Card would be available on the website
of ICICI Bank Limited only i.e. at www.icicibank.com.
16.The Company/Firm agrees that the Business Card facility is provided by ICICI Bank Limited at the request of the Company/Firm with joint and several liability of Company/ Firm and the
Card-holder to pay the total outstanding amount to ICICI Bank Limited without any delay and as per the Terms and Conditions governing the Business Card facility of ICICI Bank Limited.
17.The Company/Firm further agrees and undertakes to provide to ICICI Bank the audited balance sheets or financials of the Company/Firm within thirty (30) days of closure of the financial
year or on receipt of a specific request for the same from ICICI Bank, failing which, ICICI Bank shall reserve the right to withdraw permanently / temporarily the Business Card facility
provided to the Company.
18.I/We understand that the use of the Business Card is meant only for the official expenses as shall be approved by the Company/ Firm where I/We am employed (“Company/Firm”) from
time to time and not for my/our personal expenses.
END USE DECLARATION
I hereby represent, warrant and confirm that the loan has been taken for a valid purpose and is not speculative or illegal in any manner. I also declare that funds under the facility
will not be used to wards purchase of gold in any form, including primary gold, gold bullion, gold jewellery, gold coins, units of gold exchange traded funds (ETF) and units of gold,
mutual funds etc.
The facility either in part or full will not be used for investment in capital market, land acquisition, acquiring equity shares of Indian companies, buy back of shares of Indian
company, funding of promoters contribution in the project or any other purpose, which is prohibited or any illegal activity.
I further agree, confirm and undertake that the purpose of use of funds under the loan shall not be changed in any manner during the tenure of loan, or that such change in purpose
shall take place only with the prior written permission of ICICI bank.
I agree that any breach or default in complying with all or any of the aforesaid undertaking (s) will constitute an event of default under the facility documents.
“Disclaimer: Point 13 to 18 are for Business Credit Card application only”

Signature

To,_________________________
ICICI Bank has received your application of Loan of Rs________________________ BL00
Please note that the processing of your application may take upto 7 working days after receipt of the completed application form with requisite documents.
In case of queries, please contact. Relationship Manager :______________________________ Number:
Sales Executive / DSA :______________________________ Number:
Email ID:

You may also email us to customer.care@icicibank.com or

contact our customer care 1860 120 7777 for any complaints & queries.
Authorized Official
DETAILS OF CHARGES:

Interest Rate* ........................................................% per annum

Processing Fee (Non refundable)* Up to 2.25% of loan amount plus GST If others, please specify

Prepayment Charges* 5% of principal outstanding plus GST If others, please specify

*(Subject to change as per bank's discretion from time to time)

Note: Please visit http://www.icicibank.com for detailed charges & fees under the respective loan product. Changes in charges from time to time
are updated on bank’s website.