FASTag Application Form - ICICI Bank

1 Kindly provide the below documents if your ETC Tag balance or aggregate toll transactional value exceed ,000 at any given point in time during the month.*CorporatePublic Ltd/Private Ltd/Partnership*Certificate of Incorporation/Partnershipfirm*PAN Card of Proprietor*PAN Card of the corporatePAN CardProof*Photo ID of signing authorityGST Registration CertificateList of Directors with addresses/Name and addresses of PartnersProprietorshipDeed/Registration certificate of thePAN Card NumberNumber*Shop Act or other FirmGST Registration Certificate*IndividualPlease submit ID proof and Address proof documents from the following list of valid documents PassportVoter ID Card(for individual customer transactions not exceeding the aggregate sum of ,000 per month)*Proof of Identity Document Number: PAYMENT DETAILSC hequeCash *NEFT(*Payment by cash is acceptableONLY at select POS locations)Amount:Cheque Date:Payment Mode.

2 Cheque Details:Cheque No.:Others(Please Specify)UTR No.:`(For Official use only)ANNEXUREC harges applicable on ICICI Bank Tag:PARTICULARSAMOUNT (INR)Tag Joining FeePlease note joining fee is inclusive of fee will be applicable for online recharge which is charged by payment gateway service provider3. Charges mentioned above are subject to change. Please for the latest changes One time Tag Deposit amount (Refundable):Tag ClassDescriptionTag ColorTag DepositThreshold Amount4 Car / Jeep / VanViolet2002004 TATA Ace and Similar mini Light Commercial VehicleViolet2001005 Light Commercial Vehicle/Mini BusOrange3001406 Bus 3- AxleYellow4003006 Truck 3 AxleYellow5003007 Bus 2 Axle /Truck 2- AxleGreen40030012 Tractor / Tractor with trailer / Truck 4 / 5 / 6 AxlePink50030015 Truck 7 Axle and aboveBlue50030016 Earth Moving / Heavy Construction MachineryBlack500300 Note: The above mentioned Tag deposit rates would be applicable depending on your vehicle class and would be refunded to you at the time of ICICI Bank FASTag account closure.

3 For more information about your account andapplicable rates, please visit documents scrutinized and found in order by official at Agent locationAll documents completedand submitted on:DDMMYYYYS ignature of the POS Agent Official/Bank OfficialPOS VSTS No.: Bank Official Name and Employee Id: VEHICLE DETAILS FOR OFFICIAL USE ONLY: ICICI Bank FASTag Customer Id: Application Reference Number:Transaction Date:DDMMYYYYT otal Amount Received:` I confirm the form has been signed by the applicant in my also confirm the documents provided by the applicant have been verified with the originals.*License Plate Number/ Engine Number/Chasis Number*Vehicle Type /Vehicle Class*ICICIB ankfundedY/N*Mobile No.

4 * Tag DepositAmountPlaza Name for monthly passTotal (`):Total no. of tags applied( Use annexure if more than 8)for:Primary Bank for recharging the ETC Tags: Annexure Used:YesNoAnnexure Number: (If Annexure is used for listing vehicles) CONSUMER RECEIPTC ustomer Name:Total Amount uploaded onTotal amount receivedICICI Bank Tag:`from the customer:`Point of Sale (POS) kiosk name : Location: Date.

5 DDMMYYYYS tamp of POS agency with date: ICICI Bank FASTag is issued by ICICI Bank Ltd.*Terms and conditions apply Point of Sale (POS) collect fee(s) from customers on behalf of ICICI Bank Care: 1800 210 0104 Employee name andPlease ensure that prior to submitting the Application form you have received the ICICI Bank FASTag product leaflet and have understood the: Schedule of Rates and Charges Refer for detailed Terms and ConditionsSignature of the authorized signatory / Individual Customer DECLARATIONI declare, confirm, and agree have read,understood and hereby agree to the terms and conditions as applicable to ICICI Bank FASTag as set forth on the website which may be amended from time to time.

6 I understand that access to any changes/updation in terms and conditions applicable to this account/relationship would be available on the website onlyand I shall agree to abide by the the particulars and information given in this Application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and I havenot withheld any information. I agree and undertake to provide any further information that ICICI Bank/its Group Companies may require from time to understand that ICICI Bank Limited ( ICICI Bank ) reserves the right to reject my Application without providing any reason. I agree and understand that ICICI Bank/its GroupCompanies reserve the right to retain the Application forms, and the documents provided herewith and will not return the same to authorize ICICI Bank/its Group Companies or there agents to make references and enquires which ICICI Bank/its Group Companies consider necessary in respect of or in relation toinformation in this inform ICICI Bank & its Group Companies immediately regarding any change in any of the information provided by me in this Application form and to provide any further informationthat ICICI Bank & its Group Companies may require from time to authorize ICICI Bank/its Group Companies to exchange, share or part with all the information.

7 Data or documents relating to my Application with other ICICI Group Companies/ Banks/Financial Instruction /Credit bureaus/Agencies/Statutory Bodies or any other persons as ICICI Bank/its Group Companies may deem necessary or appropriate or as may be required for use or processing of the said information/data by such person or ICICI Bank/its group companies and shall not hold ICICI Bank/its Group Companies liable for the use/sharing of this information by either ICICI Bank or such third authorize ICICI Bank unconditionally and irrevocably to debit the relevant fees and charges applicable to the ICICI Bank Tag (as mentioned in the Terms and Conditions , Scheduleof Charges and Product Leaflet" ) from the funds available in my ICICI Bank Tag declare that the information I have provided is accurate and complete to the best of my knowledge.

8 I authorize ICICI Bank & its representatives to call or SMS me with reference to my Tag and ancillary product applications . This consent will override any registration for DNC/NDNC which you may have authorize ICICI Bank to unconditionally use my Aadhaar details as provided with my ICICI Bank Savings/Current Account or any other product I may have availed from ICICI have understood the offer and details of the Value Added Service provided by ICICI Bank. I am willingly subscribing to the VAS offering and promise to pay the sum payable foravailing the hereby give my consent to use/exchange or share my Aadhaar number, Aadhaar information for registration of client information with Exchange, KRA, CERSAI and with any otherregulatory agency of ICICI Bank which it deems fit or as per requirements of law.

9 How to recharge your ICICI Bank FASTag account ? ICICI Bank FASTag can be recharged through modes like- internet banking, NEFT/RTGS, UPI, credit card, debit card, cheque, cash online recharges: Visit with your username and password Go to Payments Recharge account Select Tag/CUG wallet recharge as applicable and choose the payment made as per your convenience Choose from one of the following options available For more details, Terms and Conditions, kindly visit www . optionsFunds upload timeConvenience fee# ICICI Bank CIB and RIBReal timeNilUPIReal timeNilDebit cardReal of the transaction value*Credit cardReal of transaction value*Internet bankingReal time1%- of the transaction value*NEFTAs per NEFT cycle CUG wallet recharge: Free or NEFT/RTGS charged as levied by source bank Tag Wallet Recharge: per transaction for tag level rechargeChequeICICI Bank - T plus one Other Bank - T plus four(T is the time or the date when thetransaction is initiated.)

10 NilPlus,taxes as per the prevailing Application rates.# Convenience fee is levied by the payment gateway for the services provided and not by ICICI Bank. The fee is levied against the cost of transaction and not for revenue inthe FASTag program.*Convenience fee may change basis the payment gateway selected and/or change in commercials between ICICI Bank and the payment gateway .Payment Gateway ModeBilldeskRazorpayDebit card (Visa/Master Card)Below and equal to &above and equal to & above Express Credit Card & Diners bankingFor HDFC and other 11. Yes/Axis-INR ICICI /Kotak/SCB-INR Rest-INR offline recharge modes Recharge through cash/cheque is available in selected point of sales (POS) locations. For more details, please contact the Customer Care on 1800 210 0104 or