APPLICATION FORM FOR FUND

TRANSFER THROUGH RTGS/BEFTN

BRANCH NAME KANCHAN BRANCH DATE 0 5 0 9 2 0 2 4 TIME
Request Type RTGS [ Customer to Customer Credit Transfer FI to FI Credit Transfer]
BEFTN [ CIE PPD CCD CTX]
[CIE: Customer Initiated Entry, PPD: Pre-arranged Payment & Deposit, CCD: Cash Concentration or Disbursement, CTX: Corporate Trade
Exchange]

SENDER/REMITTER DETAILS BENEFICIARY DETAILS

Sender Name Weber Power Solutions Ltd. Beneficiary Name CITY MART
Sender A/C No 1111 11100000171 Beneficiary A/C No 1503532909001
Address H:10, R:06, Sector:01, Uttara, Dhaka. Address
Contact No 01988 463592 Bank Name CITY BANK PLC.
Document Type NID Passport Driving Branch Name
SONARGAON JANAPATH BRANCH
License
Document Routing No.
225260241
Number
Status Resident Non Resident Currency BDT USD GBP CAD JPY
Nationality BANGLADESHI Amount BDT. 36,43,120.00
Amount in words Thirty-Six Lakh forty-three thousand one hundred twenty only.
Purpose Business
DECLARATION
I/We confirm the information given above is complete & accurate & I/we agree to comply with the terms & conditions
of Modhumoti Bank Limited RTGS/BEFTN fund transfer service
Applicant’s Signature Applicant’s Signature Applicant’s Signature Signature Verify Date

FOR MODHUMOTI BANK LIMITED, OFFICIAL USE ONLY

Amount Received Vide Cash A/C Transfer Cheque (Cheque No: Date:
Request Received By Request Received Date & Time
Request Processed By Authorized By
Request Processed Date & Authorizer P.A. No
Time
RTGS/EFT transaction Ref No CBS Transaction Ref No

CUSTOMER
ACKNOWLEDGEMENT
I/We Have Received Application for RTGS BEFTN For an Amount of BDT. 36,43,120.00Vides Transfer/Cash/Cheque
No. ……. To Be Credited to Account Number 1503532909001 of CITY BANK PLC., SONARGAON JANAPATH BRANCH. The
Customer Will Be Guided by The Terms & Conditions of Modhumoti Bank RTGS/BEFTN Fund Transfer Service.
Modhumoti Bank Limited will accept no liability for any consequences arising out of erroneous details as provided by
the customer(s).

Received Date & Time

Received with seal & signature
Terms & Conditions
01. I/We hereby authorize Modhumoti Bank Limited to carry out the RTGS/BEFTN transaction as per details
mentioned overleaf.
02. I/We hereby agree that the overleaf details including the beneficiary account is correct.
03. I/We further acknowledge that Modhumoti Bank Limited will accept no liability for any consequences arising
out of erroneous details provide by me/us.
04. I/We agree that the credit will be affected solely on the beneficiary account number provided by the sender.
05. I/We agree that the bank to debit my/our account with the charges plus taxes as applicable for this
transaction.
06. I/We agree that requests submitted after the cut off time will be sent in next batch or next working day as
applicable.
07. I/we hereby agree & understand that the RTGS/BEFTN request is subject to the Bangladesh Bank regulations
& guidelines.
08. I/we also understand that the remitting Bank shall not be liable for any loss of damage arising or resulting
from delay in transmission delivery or non-delivery of electronic message or any mistake, omission, or error
in transmission or delivery thereof or in deciphering the message from any cause whatsoever or from its
misinterpretation received or the action of the destination Bank or any act or even beyond control.
09. I/We agree that incase of EFT transaction & if we do not have an account with Modhumoti Bank Limited, we
will produce original identification proof while submitting the request. If requires we will also submit the
proof of address or any other document (s) related to this transaction as advised by the Bank.

________________________ ____________________________________
Applicant Signature with date Joint applicant(s) signature with Date (if any)