MSMED Registration No
I / We hereby declare that the particulars given above true , correct and that I have read, understood
and agree to abide by the Terms and Condition gopverning the NEFT payment facility as appended
hereto as displayed on the website at www.icicibank.com I undertake to keep ICICI Bank informed
of any charges in any of the above mentioned
Place: MUMBAI
Date: 17/08/2012
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(signatur of vendor along with rubber stamp)