ELECTRONIC CLEARING SERVICE (DEBIT CLEARING) MANDATE FORM

The Manager
………….. Bank
…………………
…………………
Telephone No: ………………….

This is to inform I / we have registered for the RBI's Electronic Clearing Service (Debit Clearing) and that payments towards <<
Children’s Valley >> shall be made from my / our below-mentioned bank account number with your bank.
I / We authorize << Children’s Valley >> acting through their bank to get this ECS Mandate form verified & executed.
I hereby authorize you to debit my account for making payment to << Children’s Valley >> through ECS (Debit) clearing as per
the details given as under: -

A. 9-DIGIT MICR CODE NUMBER OF BANK &

BRANCH:
(Appearing on the MICR cheque issued by the bank)
(MICR code starting and /or ending with 000 are not valid for ECS)

B. ACCOUNT Type: Savings Current Cash Credit

(for NRE/NRO a/cs, please tick Savings account type)

C. LEDGER NO / LEDGER FOLIO NO: ______________________________________

D. ACCOUNT NUMBER:

E. ACCOUNT HOLDER NAME(S) (As per Bank’s record)

(In case of Joint account, please mention both the names separated by ‘/’)

Name of the Date of Periodicity Amount of installment OR Number of installments OR

Scheme effect Amt of bill with upper limit Valid up to (in case of utility
(of First (M/BiM/Qly/etc) bills) (Strike out any one)
(Strike out any one)
ECS Debit)*
FEE PAYMENT

*(It will take at least 25 working days to get the mandate registered)

F. Do you wish to subscribe to Mobile alert facility on behalf of Children’s Valley? If yes, then please mention your mobile
number: + 91-____________

I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for
reasons of incomplete or incorrect information, I would not hold the user institution responsible. I have read the option invitation
letter and agree to discharge the responsibility expected of me as a participant under the scheme.

______________________________________________________
Signature/s of the Account Holder(s)
Date

Certified that the particulars furnished above are correct as per our records.

(Bank’s Stamp) ----------------------------------

Date Signature of the Authorized official from the Bank

(Note: - Mandate to be obtained in 3 copies, Original for the end customer’s Bank, One for PCM Client Company and other for the
end customer)