Amex Ecs Enrollment Form

I/we understand that AEBC may decline this application at its absolute and sole discretion. Basic Applicant s Signature Source Code Date MR Code MUD Code ECS ENROLLMENT FORM FORM A To Cyber City Tower C DLF Bldg. I further request you to inform AEBC of any changes in the status of my account. Once the American Express Card gets renewed for membership the ECS facility attached to the Card will get automatically renewed. Start Date - The date of signing the form End Date - Till revoked by me in writing to American Express Banking Corp. and to you. Name 2. Card Number 3. Particulars of Bank Account a Name of Account Holder b Bank Name c Branch Address d 9 digit code number of the bank and branch appearing on the MICR cheque issued by the bank Please attach a cancelled blank cheque or its photocopy e Account type f Ledger Folio Number Savings/Current/CC Account with code 10/11/13 If appearing on the cheque book g Account Number Yes I have attached a cancelled blank cheque or its photocopy Signature of Account Holder Date For Bank Account in Delhi Mumbai Chennai Bengaluru and Kolkata only. FORM B I the undersigned hold a Charge Card. I understand that Charge Card means any Basic Charge Card issued by American Express that has the trade mark or logo or service mark or the name American Express either in conjunction with any other name or otherwise on the face of it. I wish to avail of the Direct Debit facility and hereby express my unconditional consent to debit payment of the amount of the monthly bills of my Card Account or of any replacement/renewal Card that may be issued on the Card Account in lieu thereof through participation in the Electronic Clearing System ECS of the National Clearing Cell of the Reserve Bank of India. I also unconditionally and irrevocably authorize American Express Banking Corp. AEBC to raise debits for such regular payments against my with Bank. FORM B I the undersigned hold a Charge Card. I understand that Charge Card means any Basic Charge Card issued by American Express that has the trade mark or logo or service mark or the name American Express either in conjunction with any other name or otherwise on the face of it. I wish to avail of the Direct Debit facility and hereby express my unconditional consent to debit payment of the amount of the monthly bills of my Card Account or of any replacement/renewal Card that may be issued on the Card Account in lieu thereof through participation in the Electronic Clearing System ECS of the National Clearing Cell of the Reserve Bank of India. I also unconditionally and irrevocably authorize American Express Banking Corp. AEBC to raise debits for such regular payments against my with Bank. I hereby declare that the particulars given above are true and complete. If the transactions based on my above instructions are delayed or are not affected for any reasons whatsoever I agree not to hold AEBC responsible for any loss/ damage/inconvenience that may arise.