CGHS: Mandate Form for Individuals for ECS Facility for receiving Payment
MANDATE FORM FOR INDIVIDUALS
A. Details of Account Holder
| 1. | Name of the Account Holder | |
| 2. | Complete contact address | |
| 3. | Telephone number/fax/email |
B. Bank Account Details:
| 1. | Bank Name | |
| 2. | Branch name with complete address, telephone number and email | |
| 3. | Whether branch is computerized | |
| 4. | Whether the branch is RTGS enabled. If yes, what is the IFSC code? | |
| 5. | Is the branch also NEFT enabled | |
| 6. | Type of bank account (SB, Current/Cash credit) | |
| 7. | Complete bank account number (latest) | |
| 8. | MICR code of the bank |
Date of Effect-
I hereby declare that the particulars given 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 the read option invitation letter and agree to discharge responsibility expected of me as a participant under the Scheme.
Signature of Customer
Certified that the particulars furnished above are correct as per records.
(Bank Stamp)
Dated:-……………..
Signature of the Authorized officer from the Bank
1. Please attach a photocopy of cheque along with the verification obtained from the Bank.
2. in case your Bank Branch is presently not , “RTGS enabled” then upon up gradation to RTGS Enabled” branch. Please submit the information again in the above proforma to the Department at the earliest.
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