Service Request No.

Date :

Stay Connected
(Update your latest contact details/Address/PAN/Date of Birth/ AadharNumber – For Resident Individuals)

Customer Details: Customer ID

Bank Account: Demat Account:

I-direct Account: Credit Card:

Loan: ICICI Prudential Policy:

(Please fill in all the details in CAPITAL LETTERS and use BLACK INK only. Fields with(*) are mandatory)
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* Name: Mr./Ms./Mrs./Dr.
(Primary Applicant): First Name Middle Name Last Name
Customer Declaration:Please update my/our records with your bank for the accounts that are held by me/us. Please tick the appropriate mailing address
New Communication Address:

City: State:

Pin code: Tel No. (res.):

Tel No. (off): *Mobile No:

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

I confirm having checked my mobile number and I also authorise the bank to contact me on the above mentioned number for
verification call back or checks to confirm the veracity of any transaction, as deemed fit by the bank. I confirm that the said mobile
number is held by me and is not in use by any third party
*E-mail ID :
I wish to register for E-mail statement : Yes No
*If your new communication address is different from your permanent address, please give the details below:
Permanent Address:

City: State:

Pin code: Tel No. (Res.):

Tel No. (off.):

# For change of address, please submit relevant address proof which will be verified with the original by officials.
(A) I wish to update details in my ICICI Prudential policy number: Yes No
(B) Date of Birth:

PAN Updation: Please update my PAN in the above mentioned account.(The copy of PAN
as document proof is enclosed for the Bank's records)
(D) Passport Number:
(E) Unique Identification number (Aadhar) Updation: Please update my Aadhar Number
in the above mentioned saving bank account. (The copy of Unique ID card as document proof is required)
1. I authorize Unique Identification Authority of India (UIDAI) to release my demographic details (Including e-mail id and
mobile number) to ICICI Bank through biometric authentication which ICICI Bank may use for KYC verification (In case of
KYC)
2. I understand that Aadhar card number updated in bank A/c will be shared with National Payment corporation of India
(NPCI) for receiving direct benefit transfer credits.

Checking your account balance or requesting a mini statement, banking is now easy as messaging a friend. With SMS, you can stay in touch with your
account with just a few key words. Simply SMS the following keywords to 9215676766
•Bank Account : Primary Account
•Balance Enquiry : IBAL
•Last 3 transactions : ITRAN
•Cheque Status Enquiry : ICSI Cheque No.
•Stop Cheque Request : ISCR Cheque No.
•Cheque Book Request : ICBR
•View Presented Bills : IVIEW (space) Biller Nickname
ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED Page 1 of 2
 I/We hereby understand that:
• All the particulars filled in the form are true, correct, complete and up-to-date in all respects and no information is
withheld
• I/We understand that certain particulars given by me/us are required as per the operational guidelines governing
banking companies
• ICICI Bank reserves the right to reject the request for updating Change of address/Mobile number/E-mail ID/PAN
updation / Aadhar Number /Mobile Banking facility for one or more of the products/services without assigning any
reason
• If incomplete or inaccurate information is given, ICICI Bank, before rejecting/accepting any of the above request for
any of its products, has the right to ask for additional documents
• It is my/our responsibility to inform ICICI Bank immediately if there is any change in the address/mobile number/
E-mail ID mentioned herein and to provide further information as may be required by ICICI Bank
• Mobile Banking facility is not offered for jointly operated accounts
• I/We confirm and undertake that I/We have read and understood the Terms and Conditions governing the mobile
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banking facility of ICICI Bank as mentioned/specified on www.icicibank.com

# I confirm that I have the necessary authority/mandate from all the joint account holders to sign this declaration on behalf of
myself and all the joint holders for all the products and services mentioned herein

Customer Signature (s) :

Signature Signature Signature

Name Name Name

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

*(Primary Applicant) *(Joint Applicant 1) *(Joint Applicant 2)

Branch Use Only

Declaration by Branch Official – I confirm

The details match with the Bank's records

The applicant(s) signed in my presence and the signature(s) have been verified with the Bank records
Documentary proof is enclosed (If the account activation date is less than 6 months from the date of application)
All documents are verified with original and attested
Account is not Inactive / Dormant / Frozen / in Debit balance
Address change authorised
Identity proof is attached for the mobile banking facility
For ICICI prudential policy address updation, applicant’s address proof obtained additionally
For updation in Demat account / I-direct account

• Linked Bank Account No.___________________________________________

• Trading user ID (for ICICI Direct.com account only)___________________________________________

Employee ID: ______________________________ Bank

Seal

Signature of Bank Official: ______________________________

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

Acknowledgement Slip (To be filled by the Bank staff)

Date :
Received from ___________________________ Ac/ No./ Policy No. ______________________________________for change of address
contact details/e-mail/PAN/Mobile alert/Aadhar number for your:
Bank Account Demat Account ICICI Direct Credit Cards Loans ICICI Prudential policy
Bank
The necessary changes will be carried out in the Banks records only for the account mentioned above.
Seal
ICICI Bank (Branch Name):_____________________________ Signature of Bank Official: ____________________________
ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED Page 2 of 2