Vendor's Address:: Authorised Signatory & Stamp

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To,

Reliance JIO Infocomm Ltd


MDM Cell,
SSO - Master Data Management (MDM),
TC 23, A - Wing, 10th Floor, WS-279,
Reliance Corporate Park,
Thane Belapur Road, Ghansoli,
Mumbai - 400 701

Dear Sir,

Sub: E–Payments vide RTGS/NEFT

I/We request and hereby authorise you to execute E-Payment vide RTGS/NEFT modes to My /Our Bank account as per the details given below:

1. Particulars of Vendor

A. Vendor code :
B. Vendor’s Name as in the bank :
C. Name of Account holder :
D. Permanent Account Number (PAN) :
E. Contact Person :
F. E-Mail id for payment advice :
G. Telephone/Mobile no. :
H. Vendor’s Address :

2. Particulars of Bank Account


A. Bank Account Number
   

B. Name of the Bank & Branch :

C. Telephone No. with STD Code :

D. Bank Branch E-Mail ID :

E. 9-Digit Bank / Branch MICR Code :

F. 11-Digit IFSC Code :

G. Account Type : Current Cash Credit Saving

I/We hereby declare that the particulars given above are correct and complete. I/We confirm that I/we shall bear the charges, if any levied by my/our
bank for the credit in our above account through NEFT. If the transaction is delayed or lost because of incomplete or incorrect information, we would
not hold the company responsible.

Thanking you,

___________________________
Date: Authorised Signatory & Stamp
………………………………………………………………………………………………………………………………..
Bank Certificate
We confirm that the details given above are correct as per our records.

Date: ___________________________________
Place: Signature, Code & Stamp of Authorised Bank Official

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