-7.

flrtrt, Bank
MANDATE FORM

BY

VENDOR \TRACTOR ' ^ ' YEE FOR EFT TGS

'FFT PAYMENT
1.NAME OF THE FIRM/PERSON/PARTY : SHRI DHANIRAM LAMINATES PW LTD

2.ADDRESS: (The same should be mentioned in all bills) URKURA ROAD.RAWABHATA.RAIPUB-

492001.C.G.

TELEPHONE NO AND FAX : 0771-2563169 : FAX : 0771-2563518

CELL PHON E Email d ha niram lam @ rediffmail.com

3. PAN NO. : AACCM8218R

4. PARTICULARS OF BANK ACCOUNT:

(|)BANK NAME : ICICI BANK LTD

(|| ) BRANCH NAM E & ADDRESS : TELI BAN DHA. RAI PU R.CH HATT|SGARH.492006

(ilr) BANK BRANCH TELEPHONE NO :

(lV) ACCOUNT TYPE (whether SB or Current) : CASH CREDT A/C

(V) ACCOUNT NO : 427705000089

(Vl) BANK'S MICR CODE : 49222901.4

(vil) BANK'S rFSC CODE : tc1c0004277

5. DECLARATION OF THE PARTY:

I hereby declare that the particulars given above are correctind complete.lf he transaction
is delayed or not affected at all for reasons of incomplete and incorrect information,the user institution
i.e. will not be responsible.l have understood the scheme and agree to discharge the
responsibilty for which I am liable as a participant under the scheme.

Date: 23^Ol-2o1 q Sisnature of the Suppl ier/Partv/Emplovee

lGlGl Bank Limited

SLT Water Front, ClCl Bank Tower, Near Chakli Circle,
Shop No 212 Old Padra Road, Vadodara 390 007,
Opposite Marine Drive lndia.
Telibandha Website www.icicibank.com Corp. Office : lClCl Bank Towers, Bandra-Kurla
Raipur 492 006. CfN Complex, Mumbai 400051, India.