BANK OF INDIA

BANK OF INDIA

___________________________Branch

RTGS APPLICATION FORM ( STAR INSTA REMIT)

( To be filled by the applicant in block letter)

Date :

Details of the applicant(Remitter)1Title of the account Maa Bhambhori Tyres

2Account number489220110000055

3Type of accountCurrent

4Address and phone numberMain Road, Phushro

+91-9801320410

Detail of Beneficiary :

1Beneficiarys account BIRLA TYRES PROP.K.I.Ltd

2Address KOLKATA

3Name of Bank CITI BANK

4Name Of Branch & AddressKANAK BUILDING 41. JAWAHAR LAL NEHRU , KOLKATA 71

5IFSC numberCITI0000001

6Account NumberBDNB000M008

7Account TypeCurrent Account

Remittance Detail :

1Account to be Remitted Rs.

2Bank Charge Rs. (Rs 2.50 per 1000 /- min

Rs. 50 /- max 2500)

3Total

4Amount in Words

5Purpose of Remittance

I lease remit the amount as per above detail by debiting my/our account for the amount of remittance plus your charge. I/We have read terms and conditions of the RTGC remittance mentioned overleaf and shall abide by the same.

__________________

(Authorized Signature)

FOR BANK USE ONLYDate of transferTxn ref numberURT numberScroll numberAuthorized Signature

1.

2.