8/12/2019 Dematerialisation Request Form Only for NRI

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Dematerialisation Request Form (DRF)

ICICI Bank Ltd - Demat Services

C/o. 3i Infotech Limited, Akruti Trade Centre, 3rd Floor

P.10, Road No.7, MIDC Marol, Bhimnagar, Andheri (East)

Mumbai -400 093, Maharashtra

REGISTRAR COPY

Date of receipt:

CPO Sr. No.: . ..............................................

D D M M Y Y Y Y

INDOC no. ............................................................. Sequence no. ................................................... Date D D M M Y Y Y Y

I/We hereby request ICICI Bank to dematerialise the enclosed certificates into my/our demat account as per the details given below:

Account no. Mobile no.:

Email: . ........................................................................................................................................................................................................

Account holder name First/Sole holder

Second holder

Third holder

Quantity of securities to be dematerialised (in figures) (in words)

Name of the securities Face value: Rs.

ISIN (To be filled in by DP) IN

Details of securities Type of securities: Equity Others

Folio no. Certificate no. Quantity (in figures) From distinctive no. To distinctive no.

In case the space is insufficient, please attach an annexure containing the details of the certificate in the same format.

Submit different DRF for security certificates of the same company having different ISINs. Bonds and Debentures of different series issued by the same company

generally have different ISINs. Verity them from the branch if in doubt.

Please use separate form for free securities and locked-in securities.

Total no. of certificates surrendered: . .......................................................................................Please tick if the dematerialisation request is for locked shares. Lock-in release date:

Lock-in reason: . ......................................................................................................................................................................................................................

Declaration: I/We hereby declare that the above-mentioned securities are registered in my/our name. The original certificate(s) is/are hereby surrendered by me/us for

dematerialisation. I/We also hereby declare that the securities submitted by me/us for dematerialisation are free from any lien or charge or encumbrance and

represents the bonafide securities of the company to the best of my/our knowledge and belief.

D D M M Y Y Y Y

Holders signture(s) (If the signature registered with the Company/Registrar is different from the specimen signature given to the DP please affix

both signatures on the DRF)

Name Signature

First/Sole holder

Second holder

Third holder

DP ID

DRF

For ICICI Bank use only

To be filled in by holder(s)

For ICICI Bank use only

Participant AuthorisationReceived the above mentioned securities for dematerialisation. The application form has been verified with the certificates surrendered fordematerialisation and certify that the application form is in accordance with the delails mentioned in the enclosed certificates. It is also certifiedthat the holders hold beneficiary accounts with us in the same name.Fowarded byName of the DP official:. .........................................................................................................................................................................................................

SIGNATURE PARTICIPANTS STAMP & DATE

Acknowledgement (To be filled in by holder(s))

ICICI Bank Ltd Demat Services DP ID DRF

C/o. 3i Infotech Limited

Akruti Trade Centre, 3rd Floor, P.10, Road No.7, MIDC Marol

Bhimnagar, Andheri (East), Mumbai 400 093, Maharashtra

We hereby acknowledge the receipt of . ............................................. certificate(s) for ................................. Equity/Others (Specify) ............................of . ...................................................... surrendered for dematerialisation by ........................................having Client ID ...................................................

AUTHORISED SIGNATORYFOR ICICI BANK LTD

SUBJECT TO VERIFICATION

Date D D M M Y Y Y Y

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