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|
B. Bank Account Details:
|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.
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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