MAPIN DEBIT AUTHORISATION FORM

Date: ___________________

Customer name: _________________________________

Place: _______________

E-Brokerage: 8500________

User-Id: ________________

To

ICICI BANK LTD

Mumbai  

I intend to register myself and obtain Unique Identification Numbers (UIN), also referred to as MAPIN, from ICICI BANK LTD, one of the SEBI appointed POS for MAPIN registrations.

I hereby authorize you

1. To debit my ICICI bank account no. _________________    with a sum of Rs. 300/- towards  the fees payable to SEBI for MAPIN registration, and issue a consolidated demand draft/credit to SEBI.

2. I agree that in case the above amount of Rs. 300/- could not be debited by you from my above mentioned bank account then my application for MAPIN would not be processed by you.

I agree that the above registration process will be completed by you on a best effort basis.

Thanking you

Yours faithfully

Customer signature