BANK

CUSTOMER REQUEST FORM

Please strike off the fields which are not applicable
Ao"'t
For Branch Office Use Only (Encircle Requested SR/s)

The Branch Head

Axis Bank Ltd. Branch | 5ol lD: Date of Request:

Customer Name:

Customer ld: Account Number:

1. MoBILE NUMBER UPDATE/REGISTRATION :

Avail following Services - Transaction Alerts (Tick on the "Subscribe" Option Below), Get Balance & Last 3 txns through SMS,
financial txns on internet banking, Duplicate Debit Card/ Pin Request.
ALERTS: | | Subscribe | | Unsubscribe
(All alerts will be sent. Charges applicable @Rs S/month) (Only Mandatory Alerts will be sent. For e.g. All card based &
Internet Banking transa(
2. LANDLINE NUMBER UPDATE (Res):

LANDLINE NUMBER UPDATE (Off):

3. EMAIL ID (FOR E-STATEMENT REGISTRAT1ON): ln case E-Statements are activated, physical statements will be disabled

4. PERMANENT ACCOUNT NUMBER (PAN) DETAILS:

5. AADHAR NUMBER :

6. CHANGE OF MAILING ADDRESS (ln case of joint holders, each holder needs to fill a separate form)

Landm'arkr: STATE* :

City*: Pin Coder:

DOCUMENT FOR PROOF OF ADDRESS (Mandatory for change in Mailing Address):

DOCUMENT IDENTIFICATION NUMBER:

ISSUING AUTHORITY: PLACE OF ISSUE:

ISSUE DATE VALID TILL

7. NEW CHEQUE BOOK REQUEST: Number of Cheque Book/s Required:

8. ACCOUNT ACTIVATION: PLEASE REACTIVATE MY ACCOUNT NUMBER

REASON FOR NOT OPERATING THE ACCOUNT:

9. OTHERS

I have read, understood and agree tothe terms and conditionsto various products and seruices including SMS Banking, E-Statement and lnternet Banking. I accept and agree

to be bounded bythe Terms and Conditions as displayed on ww.axisbank.coBl agreethat the bank may debit service charges plustaxesto my account wherever applicable.

DATE: PLACE:' CUSTOMER SIGNATURE:

FOR BRANCH OFFICE USE ONLY

Certi{ied that this Request Letter is complete in all respect & all relevant documents are obtained & verifieil mode of operation and signatures ofthe Vc. lhe
request may please be processed.

| | BANK TNDUCED REg

REQUEST RECEIVED DATE: FORWARDEDTO CLH DATE:

REQUEST ACCEPTED BY: EMPLOYEE NUIVIBER: <,IGNATURE:

Request Certified By Signature

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ACKNOWLEDGEMENT TO CUSTOMER
Customer Name:
Date of Request Received:
Name of Branch Official:
- Sigiature:
 AXIS BANK
CUSTOMER REqUEST FORM
Please strike off the fields which are not applicable

10. DUPTICATESTATEMENT
Statement Required From Date: To Date;

11. DEBIT CARD

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12. STOP PAYMENTREQUEST uo
Number of Cheques:
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Payees Name: Or
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Cheque Number(s): tr

Date of Cheque: Reason for Stop Payment:

Amount:

13. REVERSATOFCHARGES

Date of Debit: Amount of Debit: Rs

I undertake to keep henceforth an Average Monthly / Quarterly / Half Yearly Balance of Rs. (ln case of Average Balance
Non-Maintenance Charges only):

14. [ ssuANcEoF PAssBooK

rs. I srGNAruRE vERrFrcATroN

16. ANY OTHER (Please Specify)

I have read, understood and agree to fhe terms and conditions to various products and services. I accept and agree to be
bounded by the Terms and Conditions as displayed on www.axisbank.com. I agree that the bank may debit service charges plus
taxes to my account wherever applicable.

DATE: PIACE: CUSTOMER SIGNATURE:

FOR BRANCH OFFICE USE ONTY

Certified that this Request Letter is complete in all respect & all relevant documents are obtained & verified mode of operation and
signatures of the A/c. The request may please be processed.

I I BANK TNDUCED REQUEST

REQUEST RECEIVED DATE: FORWARDED TO CLH DATE:

REQUEST ACCEPTED BY: EMPLOYEE NUMBER:

Request Certified By Signature Desisnarion:[] o, r,, ,.r*o,lTI-TTl

ACKNOWTEDGEMENT TO CUSTOMER
Customer Name:

Date of Request Received:

Name of Branch Official:
Signature: