TIONVENDOR CREATION Form (on the Letter Head of the vendor)

Please fill in the information in CAPITAL LETTERS. • Vendor Name :

• Vendor’s Address :

• Telephone No. :

• Mobile No. :

• Email id :

• PAN NO (Attach attested copy of PAN CARD) :

• SERVICE TAX NO (Attach copy of Form ST-2 if applicable ) :

• VAT / TIN No. (if applicable) :

• State in which VAT/ TIN is registered :

• MSMED registration No. (Attach copy of MSMED Registration certificate)

*** Vendor ’ s Bank Details

1.Name of the Bank :

2. Branch Address :

3. Location of the Branch (City) :

4. Type of Account (Saving / Current) :

5. Bank Account No. :

6. IFSC code (Attach cancel copy of the cheque) :

7.MICR Code of the Branch :

Please note: Kindly get the bank details attested by bank. Without attestation the forms

will not be accepted.

___________________ ________________________(Signature of vendor) *** (Signature of Bank Officer)(Along with Rubber Stamp) (Along with Rubber Stamp)

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I / We hereby declare that the particulars given above are true, correct and complete and

that I/ We have read, understood and agree to abide by the Terms and Conditions

governing the NEFT payment facility as appended hereto and/or as displayed on the

website at www.icicibank.com I / We undertake to keep ICICI Bank informed of any

changes in any of the above mentioned details.

Place :Date :

______________________________(Signature of vendor)(Along with Rubber Stamp)

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