Customer Request Form - Personal Banking & Netbanking ...

1 Customer Requests FormService Request No.:ACKNOWLEDGMENT SLIP (TO BE FILLED IN BY THE BANK STAFF)Received from_____ A/c No: Date:Nature of Request : _____Service Request No_____ICICI BANK (Branch Name and Stamp) :_____ Customer Detail (To be filled in by the Customer . Fields marked with #are mandatory.)Date:Tel No.: E-mail ID: _____The Branch Manager, _____(Branch)# Customer 's Name (as in Bank A/c)_____ #Account No.: (Please tick the appropriate boxes. Charges will apply for fields marked with *. For further details please visit our website )ATM/DEBIT Card No:. #Mobile No.:ATM/DEBIT CARDS_____*De-hotlist (unblock ATM/Debit Card) internet BANKINGFIXED DEPOSITS/RECURRING DEPOSITSLink FD to operative A/c No: (If FDR was issued, please return it)FD Receipt/MOD not received_____Incorrect tenure_____Required tenure _____Interest rate mismatchNon receipt of interest Pay Order for interest for quarter/month_____ Interest not credited for the Quarter/Month of_____ Senior citizen interest not receivedError message: _____ Transaction not functioning in internet Banking :Login TransactionSite problem: User ID_____Linked Account No.

2 : Bank Credit Card Demat Loan*Account Type:Error Date:Error page: _____ Bill Payment Fund Transfer Miscellaneous_____User ID_____Transaction Date:Credit Account No.: Amount _____Biller's name_____ *To enable User ID_____ *Reissue both Login and Transaction Password * Request for Login Password Password not received Unable to view linked accountsCHEQUE BOOKNew Cheque book Request : No of Cheque Book/s requested_____ Mailing address (please confirm if the address is updated)Branch*Non-personalised cheque book (5 Leaves) Purpose of Request _____(please submit ID proof) Cheque book not received, Request placed through:Requisition slipPhone bankingInternet bankingATM/ATM dropbox on Branch at _____ (Branch name) ATM RESPCODE:_____ ATM/Debit Card not received Card expired, new card not received Card swallowed b y ICICI ATM on Card swallowed b y NON ICICI ATM on Upgrade my Debit Card*Reissue CardReason.

3 Lost Damaged*Issue a new Debit CardName to be printed on the card:_____ Preferred delivery for ATM/Debit Card:Mailing address (please confirm if address is updated)BranchCHEQUEP ayee details required: Amount (in `)_____Cheque Drawn Cheque : _____Deposited at:_____Drawn Returned cheque not receivedDate of transaction:Date of deposit:#Signature of the Customer (as per Bank records):_____ 1 of 2--------------------------------------- ---------------------------------------- ---------------------------------------- -------------------------------------Sig nature Of Bank OfficialICICI/ 1 of 2FD No.: * Request for internet User ID and Password *Reissue only Transaction Password TDSTDS Certificate Request for the FYInterest Certificate Request for the FYTDS Certificate not received for FYCust.

4 ID15G/15H Form submitted at onbut tax deductedBranchStatement required: STATEMENTP urpose of Request _____(Charges applicable as per period of statement)STATEMENTP assbook Request Statement not received for the period :Preferred delivery: From To From To * Request for Duplicate Passbook#Signature of the Customer (as per Bank records) 2 of 2_____Address change not done: Application given on:CHANGES/ADDITIONS/DELETIONSJ oint applicant's name not includedatBranchInstruction dateJoint applicant's name_____ACCOUNT NOT OPENEDForm submitted onDate:Branch/Sales Team#Signature of the Customer (as per Bank records)NominationNot registeredNot deletedMode of operation wrongly mentioned. To be mentioned as:_____DEBIT/CREDIT ADVICE REQUESTA mount :Date of transaction :atTRANSACTION DISPUTECash not dispensed from ATMATMA mount disputed:_____(Attach copy of transaction slip)Erroneous Credit/Debit in A/c:_____Date of transaction:Amount_____Drawn on_____Charges debited to account:Amount _____Date of transaction:Insufficient cash dispensed from ATMDate of transaction:ATM RESPCODE:_____Amount:_____ATM No.

5 :_____Transaction No.:_____Addition/Deletion of Joint (s) not done instruction given on at_____Branch 2 of 2 internet Banking Password Regeneration, Cheque Book, Stop Payment, Address Change, Balance / Last 10 Transactions, Debit Card PIN Re- generation and many more with 24-hour Customer INSTRUCTIONFrom To Debit A/C A/C *Amount (in Rs.)FrequencyStanding instruction not dateatBranchCheque of Credit CardOthers (please specify_____I wish to link my credit card to Savings Bank A/C Credit Card :_____Drawn on:_____Amount credited:amount deposited:Salary not credited : Company Name:_____Amount:_____Cheque opened, funds not creditedATM Interest not credited for the month of_____Cash/Cheque Deposited:ATMD ropbox but not credited to A/CCash deposited at Branch on FUNDS NOT CREDITED TO THE A/CACCOUNT UPGRADES enior Citizen PAN:Date of birth:(Attach date of birth proof )Ahmedabad: 07933667777 / 07944455000 Bangalore: 08033667777 / 08044455000 Bhopal: 07553366777 Bhubaneswar: 06743366777 Chandigarh: 01723366777 / 01724445500 Chennai: 04433667777 / 04444455000 Dehradun.)

6 01353366777 Delhi: 01133667777 / 01144455000 Ernakulam: 04843366777 Gurgaon: 01243366777 / 01244445500 Hyderabad : 04033667777 / 04044455000 Jaipur: 01413366777 / 01414445500 Kolkata: 03333667777 / 03344455000 Lucknow: 05223366777 / 05224445500 Mumbai: 02233667777 / 02244455000 Panaji: 08323366777 Patna: 06123366777 Raipur: 07713366777 Ranchi:06513344339 Shimla: 01773366777 Assam: 9864667777 Himachal Pradesh: 9817667777 Orissa: 9692667777 Chattisgarh/Madhya Pradesh: 9098667777 Maharashtra/Goa: 9021667777 Kerala: 9020667777 Jammu & Kashmir: 9018667777 Haryana: 9017667777 Bihar/Jharkhand: 8102667777 West Bengal: 8101667777 Karnataka: 8088667777 Uttar Pradesh/Uttarakhand: 8081667777 Gujarat: 8000667777 Rajasthan: 7877667777 Punjab: 7307667777 Andhra Pradesh/Telangana: 7306667777 Tamil Nadu: 7305667777_____ICICI/ 2 of 2 DEBIT/CREDIT ADVICE REQUESTA mount :Date of transaction :STANDING INSTRUCTIONFrom To Debit A/C A/C *Amount (in Rs.)

7 FrequencyStanding instruction not dateatBranchLINKING OF CREDIT CARDI wish to link my credit card to Savings Bank A/C Credit Card :_____Drawn on:_____Amount credited:Amount deposited:Salary not credited : Company Name:_____Amount:_____Cheque opened, funds not creditedATM Interest not credited for the month of_____Cash/Cheque Deposited:ATMD ropbox but not credited to A/CCash deposited at Branch on FUNDS NOT CREDITED TO THE ACCOUNT SENIOR CITIZEN ACCOUNT UPGRADE Senior Citizen PAN:Date of birth:(Attach date of birth proof)_____Address change not done: Application given on:CHANGES/ADDITIONS/DELETIONSTRANSACTIO N DISPUTECash not dispensed from ATMATMA mount disputed:_____(Attach copy of transaction slip)Erroneous Credit/Debit in A/c:_____Date of transaction:Amount_____Drawn on_____Charges debited to account:Amount _____Date of transaction:Insufficient cash dispensed from ATMDate of transaction:ATM RESPCODE:_____Amount:_____ATM No.

8 :_____Transaction No.:_____Date:ACCOUNT NOT OPENEDForm submitted onBranch/Sales TeamCheque dateNominationNot registeredNot deletedMode of operation incorrectly updated:atBranchICICI/ 2 of 2 For Cheque Book Request , Account Balance / Last 5 transactions, Debit Card PIN Re-generation, Stop Payment and for many more services contact our Customer Care number from your registered mobile (please specify_____OTHERSJ oint applicant's name not includedJoint applicant's name_____Addition/Deletion of Joint (s) not done instruction given on at_____Branch SelfEither or SurvivorJointlyOther, please specify _____ atBranchDeclaration by Branch Official I confirm Customer called on registered mobile no_____ and reason for deliverable Request confirmedEmployee ID.)

9 _____ Date of call: _____Signature of Bank Official: _____ Time of call: _____Remarks: _____ Retail Customer Care : 1860 120 7777 Business Banking : 1860 120 6699 I Direct : 1860 123 1122 Wealth : 1800 103 8181 BankSeal internet Banking Password Regeneration, Cheque Book, Stop Payment, Address Change, Balance / Last 10 Transactions, Debit Card PIN Re- generation and many more with 24-hour Customer Care.