APPLICATION   FORM   FOR   MONTHLY PHYSICAL  STATEMENT

Yes : I wish to avail of the Monthly Statement Facility. I / We authorize ICICI Bank to debit Rs.200/- per annum plus service tax as applicable from time to time (for NRIs INR 500 per annum plus service tax as applicable from time to time) from my account number mentioned below for availing of monthly statements.

Account No:            Cust ID:

Name of Applicant: Mr./Ms./Dr

Name of Joint applicant 1 : Mr./Ms./Dr

Name of Joint applicant 2 : Mr./Ms./Dr

Note: In case of joint applicant the statement will be sent to only one applicant.

Terms  and  Conditions

I/We hereby apply for receiving physical statement of account for the above mentioned account on monthly basis.

I/We also understand that this will entitle us to an annual statement of account in the physical form at the end of each financial year

I/We also understand that I/We have to inform ICICI Bank for discontinuation of this service in writing.

I/We also understand that the amount will henceforth be debited from my account at the beginning of the each financial year for availing of the facility of monthly account statement.

I/We also understand that the amount paid towards subscribing this facility will not be refunded.

I/We agree that the above mode of sending statement of accounts is for my/our convenience. The Bank shall not be liable or responsible for any breach of secrecy or confidentiality in any manner what so ever on account of the information/statement of accounts being sent.

I/We undertake to inform ICICI Bank in writing of any change in the contact information furnished.

I/We do hereby declare that information furnished in this form is true to the best of my/our knowledge and belief.

Signature of Applicants as per the mandate of account operation

Please sign in black ink within the box.

Applicant 1. Signature     Name: Mr./Ms./Dr.

Joint Applicant 1. Signature Joint Applicant 2. Signature Name: Mr./Ms./Dr.                                                        Name: Mr./Ms./Dr.                                                        Date :                                                                           Place :