Icici Pay Direct Card – Fill Out and Use

Ref No:

Card No:

Branch Code:

DMA Code:

Company PPA Code:

Pricing Code:

Application No. :

Version 3,September 2004.

*Flat No./Society Name :

*Road No./Name :

*Nearest Landmark :

*City :

*Mother’s Maiden Name :

E-mail ID :

*Permanent Address :

C O M M U N I C A T I O N A D D R E S S

(This information may be used to verify your identity when you want your card account details over phone.)

*City :

*State :

*PIN :

IDENTITY PROOF

( Verified true copy of any one of the following valid documents duly verified with the originals by a bank official):

Passport

Original Letter of introduction from existing bank

Driving Licence

Voters identity cards

Employee identity cards

PAN Card

Photo Credit Card along with the current billing cycle (latest) statement

Arms licence issued by state/ Central Government of India authority with photograph of applicant

Pension book issued by Government of India with photograph of applicant containing name, address and validity period.

Freedom fighters pass issued by home ministry of government of India with photograph of applicant

If yes, (a) Details of ward/ Circle/Range ware the last return of income was filed

(b) Reason for not having PAN/GIR No. :

*(Copy of Pancard Mandatory )

*Name of the Company :

*Department :

*Office Address :

* City :

Address & Signature verified as per the company records

Name of Authorised Signatory :

Tel. : 2

PIN :

Extn. No . :

S I G N A T U R E S A N D P H O T O G R A P H S

Signature of Bank official in whose presence signed

Date :

DDMMYYYY

Applicant’s

Photo

I have understood and here by agree to the Terms and Conditions as applicable to my Card set forth on the website www.icicibank.com. I understand that Access to any changes/Updating in terms and conditions applicable to this relationship would be available on the website only. I do hereby declare that information furnished in this form is true to the best of my knowledge and belief.

I declare, confirm, agree:

•That all the particulars and information given in this application form ( and all documents referred or provided therewith ) are true, correct, complete and up-to-date in all respects and I have not withheld any information. I understand that certain particulars given by me are required by the operational guidelines governing banking companies. I agree and undertake to provide and further information that ICICI Bank Ltd./its Group Companies may require.

•That I have had no insolvency proceedings initiated against me nor have I ever been adjudicated insolvent.

•That I have read the application form and brochures and am/are aware of all the terms/conditions of availing finance or service or products from ICICI Bank an its group companies and/or its and ICICI Bank.

•I agree and understand that ICICI Bank limited / Group Companies reserve the right to reject any application without providing any reason. I agree and understand that ICICI Bank Ltd. /Its Group Companies reserve the right to retain the application forms, and the documents provide therewith, including photographs and will not return the same to me.

•I have also read and understood Terms and conditions under which the scheme is offered to my organisation and its employees.

•I agree that my employer has full right to revers an instruction given by them for any amount within a period of three working days and I will not dispute or hold the bank responsible for any such debits on the Card.

I understand that it is my responsibility to inform ICICI Bank immediately on termination of my employment with my current employer whereupon I will cease to enjoy any or all benefits under this scheme.

ICICI Bank/its Group Companies or there agents to make references and enquires which ICICI Bank Ltd./ Its Group Companies consider necessary in respect of or relation to information in this application. To inform ICICI Bank & its Group Companies regarding change in my residence / employment and to provide any further information that ICICI Bank & its Group Companies may require from time to time. ICICI Bank Ltd. / its Group Companies to exchange share or part with all the information data or documents relating to my application to other ICICI Group Companies/ Bank/ Financial Instruction / Credit bureaus / Agencies Statutory Bodies such other persons as ICICI Bank Ltd. /Its Group Companies may deem necessary or appropriated as may be required for use or processing of the said information/data by such person or fumishing of the processed information/data/products thereof to other Banks/Financial Institutions / Credit provider /users registered with such persons and shall not hold ICICI Bank Ltd./its Group Companies liable for use of this information

I agree and understand that I have to complete further applications for specific liability products services from ICICI Bank Ltd./ Its Group Companies as prescribed from time to time and that such further application shall be regarded as an integral part of this application and vice versa and that unless otherwise disclosed in such further forms are prescribed the particulars and information set forth herein as well as the documents referred or provide herewith are true, correct, complete and up-to-date in all respect. I agree and understand that such further application will require incorporation of the application form number, and/or such details as ICICI Bank may prescribe, to facilitate data management.

I authorise ICICI Bank Ltd. to issue an ICICI Bank Pay Direct Card / Meal Card / Reimbursement Card to me. I acknowledge that the issue and usage of the Pay Direct Card / Meal Card / Reimbursement Card is governed by the terms and conditions as in force from time to time and agree to be bound by the same. I accept that the terms and condition of Pay Direct Card / Meal Card / Reimbursement Card are liable to be amended by ICICI Bank Ltd. from time to time. I further unconditionally and irrevocably authorise ICICI Bank Ltd. To debit my Account annually with an amount equivalent to the fee and charges for use of the card. I hereby confirm that this account will be operated singly.

The Applicant/s has/have no objection to ICICI Bank Limited, its group companies, agents/representatives to provide me/us information on various products, offers and services provided by ICICI Bank Limited/its group companies through any mode (including without limitation through telephone calls/SMSs/emails) and authorise ICICI Bank Limited, its group companies, agents/representatives for the above purpose.

Signature of Applicant

Employee No.

* Date :

DD

MM

YYYY

YYYY

SE / BDE / BM / BOM Signature

Signature