Financial Overview
Investor's opting to receive Dividend Payments through Credit Clearing Mechanism
1 a) Folio No. :  
  b) DP ID * :  
  c) Client ID *
(* applicable if shares are held in Electronic Form)
2 Investor's Name :  
3 Particulars of Bank Account :  
  a) Bank Name :  
  b) Branch Address

  c) 9-Digit Code Number of the Bank and branch appearing on the MICR cheque issued by the Bank :  
  d) Account type (SB/Current/Cash Credit) :  
  e) Account No. (as appearing on the cheque book) :  
4 Date of Effect :  
I, hereby, declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I would not hold the user institution responsible. I have read the option invitation letter and agree to discharge the responsibility of me as a participant under the scheme.
Date : (Signature of the Investor)
Certificate of the Investor's Bank
Certified that the particulars furnished above are correct as per our records.
(Signature of the Authorised Official from the Bank)
Bank Stamp :

Date :
(Note : In lieu of the bank certificate to be obtained as above, Investor can attach a blank "cancelled" cheque or a photocopy thereof)