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Equity Fund
(New Fund Offer from ICICI Prudential Mutual Fund)
STANDING INSTRUCTION MAINTENANCE FOR SYSTEMATIC INVESTMENT PLAN
Existing Folio No.
The Manager, _______________________________________________________________________________________________________________ (Bank Name & Branch Address)
I/We, Mr./Ms./M/s. _____________________________________________________________________________________________ hereby authorise you to debit on a monthly basis (as a Standing
Instruction) from my/our Account No. mentioned below (hereinafter referred as “funding account”) for Rs.______________________ (Rupees ________________________________________________
only) and remit the same on account of ICICI Prudential Mutual Fund.
Sub-Options Dividend
Scheme Name: ICICI PRUDENTIAL FOCUSED EQUITY FUND Retail Option Growth
(Please tick) Dividend Payout Dividend Reinvestment
SIP Start Month/Year : July 2008
Debit A/c. No. ______________________________ SIP Date: 1st 7th 10th 15th 25th SIP End Month/Year: M M Y Y Y Y
Name of the Beneficiary: ICICI Prudential Mutual Fund Account.
I/We undertake to keep sufficient funds in the funding account on the date of execution of standing instruction. 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/we would not hold the Mutual Fund or the Bank responsible. If the date of debit to my/our account happens
to be a non banking/business day as defined in the Offer Document of the said Scheme of ICICI Prudential Mutual Fund, execution of the SIP will happen on the previous business day and allotment of units
will happen as per the Terms and Conditions listed in the Offer Document of the Mutual Fund. I/We have read and understood the Offer Document/Key Information Memorandum of ICICI Prudential Focused
Equity Fund. I/We apply for the units of ICICI Prudential Focused Equity Fund and I/we agree to abide by the terms, conditions, rules and regulations of the scheme. I/We declare that the amount invested in the
Scheme is through legitimate sources only and is not designed for the purpose of contravention or evasion of any Act, Regulation, Rule, Notification, Directions or any other applicable laws enacted by the
Government of India or any Statutory Authority.
Yours faithfully,
Signatures as in Bank Records
2nd Holder
3rd Holder
1st Holder
SYSTEMATIC INVESTMENT PLAN (SIP) AUTO DEBIT (ECS) INSTRUCTION FORM APPLICATION NO.:
List of Cities for SIP Auto Debit via ECS (Debit Clearing): Agra, Ahmedabad, Allahabad, Amritsar, Aurangabad, Bangalore, Bardhaman, Baroda, Bhopal, Bhubaneshwar, Bilwara,
Calicut, Chandigarh, Chennai, Cochin, Coimbatore, Dehradun, Durgapur, Erode, Gorakhpur, Guwahati, Gwalior, Hubli, Hyderabad, Indore, Jabalpur, Jaipur, Jalandhar, Jamshedpur,
Jammu, Jodhpur, Kanpur, Kolhapur, Kolkata, Lucknow, Ludhiana, Madurai (SIP Dates: 1st and 7th only), Mangalore, Mumbai, Mysore, Nagpur, Nasik, Nellore, New Delhi, Panjim,
Patna, Pondicherry, Pune, Raipur, Rajkot, Ranchi, Salem, Shimla, Sholapur, Silliguri, Surat, Tirupati, Tirupur, Trichur, Trivandrum, Udaipur, Varanasi, Vijaywada and Vishakhapatanam.
SIP Date: 1st 7th 10th 15th 25th SIP Start Month/Year : July 2008 SIP End Month/Year M M Y Y Y Y
Please note: SIP date for Madurai centre would be the 1st or 7th of every month whereas for the remaining centres the SIP date would be the 1st or 7th or 10th or 15th or 25th of every month.
We hereby authorise ICICI Prudential Mutual Fund and their authorised service providers to debit my/our following bank account by ECS (Debit Clearing) for collection of SIP payments.
PARTICULARS OF BANK ACCOUNT (Mandatory)
Bank Account Holders Name
3rd Holder
1st Holder
Authorisation of the Bank Account Holder
This is to inform I/we have registered for the RBI's Electronic Clearing Service (Debit Clearing) and that my payment Account
towards my investment in ICICI Prudential Mutual Fund shall be made from my/our below mentioned bank account
with your bank. I/We authorise the representative carrying this ECS mandate Form to get it verified & executed. Number
3rd Holder
1st Holder
ICICI Prudential Focused Equity Fund
(New Fund Offer from ICICI Prudential Mutual Fund)
2 ABOUT YOU
Name of First Applicant Date of Birth (Mandatory)
Mr. Ms. M/s. D D M M Y Y Y Y
Name of Guardian (in case of minor) / Contact Person (In case of non-individual investors) Status [Please tick ()]
Mr. Ms. Minor Trust
NRI/PIO* Bank/FI
Designation of the Contact Person (In case of non-individual investors) Resident Individual AOP/BoI
HUF Club/Society
Sole Proprietorship Company
Mailing Address (Please provide full address) Partnership Firm
Others (Please specify) _______
_______________________
*NRIs/PIOs applications to be
City PIN submitted ONLY at any of the
(Mandatory) designated ICICI Bank or HDFC
State Bank Collection Centres or at
Country AMC branches.
Communication
Tel. Tel.
(Off.) Mob
E-Mail
Overseas Address (in case of NRIs/FIIs)
City ZIP/P I N
(Mandatory)
State Country
(Mandatory)
Name of Second Applicant Mode of holding [Please tick ()]
Mr. Ms. Single Joint
Name of Third Applicant Anyone or Survivor
Mr. Ms. (Default option: Anyone or Survivor)
3 E-MAIL COMMUNICATION – I/We wish to receive the following via e-mail instead of physical document:
Account Statement Quarterly Review & Annual Report Other statutory information
ss
Addre
Branch Address
City
Account Number Account Type
If “Mandatory Details” are not provided,
Current Savings NRO NRE your application is liable to be rejected.
9 Digit IFSC Code
MICR code (11 digit)
Please quote 9 Digit Code No. of your Bank and Branch corresponding to Bank Account details. (This number appears on every leaf of your cheque book after your cheque
number). Please attach a blank “cancelled” Cheque or a clear photocopy of a cheque issued by your bank verifying of the Code No. The AMC reserves the right to make dividend
payments through ECS where MICR code is available.
5 YOUR INVESTMENT DETAILS
Retail Option : In case, the investor has not selected the sub-option for his investments or selected multiple sub-options, the default sub-option will be Dividend Reinvestment.
Institutional Option I : Please use a separate application form available on the website www.icicipruamc.com.
Scheme Name: Option Retail Option
ICICI PRUDENTIAL FOCUSED EQUITY FUND Dividend
Sub-Options (Please tick) Growth
Dividend Payout Dividend Reinvestment
City Cheque/DD No. Cheque/DD Date Account Type (For NRI Investors)
PIN Code
Name of the Guardian (If nominee is minor) - Mandatory Relationship with minor
PIN
Code
7 YOUR CONFIRMATION
To the Trustee, ICICI Prudential Mutual Fund – I/We have read and understood DD MM YYYY
the Offer Document/Key Information Memorandum of ICICI Prudential Focused Equity First
Fund. I/We apply for the units of ICICI Prudential Focused Equity Fund and I/we agree to abide by the terms, conditions, Applicant
SIGNATURE(S)
rules and regulations of the scheme. I/We confirm to have understood the terms & conditions, investment objectives,
investment pattern, fundamental objectives and risk factors applicable to the Scheme. I/We have understood the details
of the scheme and I/we have not received nor been induced by any rebate or gifts, directly or indirectly, in making this
investment. I/We agree to abide by the terms, conditions, rules, regulations and other statutory requirements of SEBI, Second
AMFI, Prevention of Money Laundering Act, 2002 and such other regulations as may be applicable from time to time. I/ Applicant
We declare that the amount invested in the Scheme is through legitimate sources only and is not designed for the purpose
of contravention or evasion of any Act, Regulation, Rule, Notification, Directions or any other applicable laws enacted by
the Government of India or any Statutory Authority. I/We agree that in case my/our investment in the Scheme is equal to
or more than 25% of the corpus of the Scheme, then ICICI Prudential Asset Management Co. Ltd., Investment Manager Third
to the Scheme, has full right to refund the excess to me/us to bring my/our investment below 25%. Applicant