ECS MANDATE FORM To, M/s. Karvy Consultants ... - Axis Bank Logo

ECS MANDATE FORM
To,
M/s. Karvy Consultants Limited
Unit : UTI Bank Limited
Karvy House
46, Avenue 4, Street No. 1
Banjara Hills
Hyderabad - 500 034
I hereby consent to have the amount of dividend on my equity shares credited through the
Electronic Clearing Service (Credit Clearing) – (ECS). The particulars are :
1. Folio No/Client ID No/Cert No. : _________________________________________________
2. Name of 1st Registered holder : _________________________________________________
3. Bank Details :
• Name of Bank : _______________________________
• Full address of the Branch : ___________________________________________________
• Account Number : _______________________________
• Bank Ledger No./bank ledger Folio No. : __________________________________________
• Account Type : (please tick the relevant box for Savings Bank Account, Current Account or
Cash Credit A/c)
10 – Savings 11 – Current 12 - Cash Credit
• 9 Digit Code number of the Bank and branch appearing on the MICR cheque issued by the
bank (Please attach a photocopy of a cheque for verifying the accuracy of the code
number) :
I hereby declare that the particulars given above are correct and complete. If the transaction is
delayed because of incomplete or incorrect information, I will not hold the Company
responsible.
___________________________________________
(Signature of the 1st Registered holder as per
the specimen signature with the Company)
Name : __________________________________
Date : _____________________
Address : __________________________________