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Debit Mandate Form

20110131000000224865

Authorization of the customer to remit funds to TechProcess Solutions Limited through ECS

I/We hereby authorize TechProcess Solutions Limited, the authorized service provider of ICICI Bank Limited, to debit my/our bank account by ECS Debit Clearing for collection of funds towards payment requests from Account number as mentioned below

BENEFICIARY ACCOUNT DETAILS

1. Customer Account No.:

(1)

055101514550

2.Bank Details: ICICI Bank Limited

PAYER DETAILS:

The Manager

Bank Name:

H.D.F.C. BANK LTD.

Branch Name:

RTNAGARBANGALORE

(Address)

BANGALORE

Telephone

Copy to the User Company

Name:

Address:

Tel No:

A. 9-DIGIT CODE NUMBER OF THE BANK & BRANCH: 560240009 (Appearing on the MICR cheque issued by the bank)

B. ACCOUNT TYPE : SAVING ACCOUNT (10) (S.B. Account/Current Account or Cash Credit)

C. LEDGER NO / LEDGER FOLIO NO. :

D.ACCOUNT NUMBER :

E. ACCOUNT HOLDER NAME(S) : Amareswar Nannapanen (As per bank's record)

0

1

4

0

1

6

1

0

0

0

4

7

2

9

0 1 4 0 1 6 1 0 0 0 4 7 2 9

Name of the Scheme

 

Periodicity

Amount of installment/ Amt of bill with upper limit

Number of installments/ Valid up to (in case of utility bills)

Date of effect

(M/BiM

/Qly/etc.)

Funds Transfer

31 Jan 2011

ON Request

49999

31 Jan 2016

F. Date of effect : 31 Jan 2011

I/We hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I would not hold the user institution responsible. I have read the option invitation letter and agree to discharge the responsibility expected of me as a participant under the scheme.

Date:

Full Name & Signature of the Account Holder/s

1.

2.

(Please enclose Cancelled Cheque.)

(Incase of Joint account holders, signatures required from all account holders)

Certified that the particulars furnished above are correct as per our records.

(Bank's Stamp)

Date:

Authorised Signatory of the Bank

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ICICI Bank Acknowledgement for Debit Mandate

Name of receiving official:

Signature:

Date of receipt:

Receiving Branch Name & ID:

20110131000000224865

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