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
I oelcrrveloN oF DEBtr cARD NUMBER:
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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:
