Acknowledgement Form

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MOST IMPORTANT INFORMATION
Attention: Please read carefully before signing
ACKNOWLEDGEMENT FORM
CUSTOMER’S COPY
LAN: #_____________________________
For Office Use Only)
I/We refer to final application form No. _____ dated ___________ submitted by me / us to ICICI Bank Limited. I/We have been provided
the following information and have accordingly filled up the aforesaid application form:
Vehicle Mfr. & Model:
____________________
Facility Amount Not Exceeding:
Rs.____________________
Amount of each Installment
*
:
Rs. __________________
No. of Advance Installments:
____________________nos.
Due Dates for Installments:
________ day of each month**
A) Fixed Rate of Interest:
____________________% p.a.
OR
Floating Rate of Interest:
Floating Reference Rate (FRR)
Margin % (+/ - )
Applicable Rate %: [FRR (+/-) Margin)]
Total No. of Installments:______ nos. payable in ______ months (Subject to change in FRR in case of Floating Rate of Interest)
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B) Processing Fee:
Rs.____________________
C) Stamp Duty Charges:
Rs.____________________
*The above three charges (A,B & C) comprises “All-in-cost” for processing of loan application.
D) Prepayment charges: The lesser of the following two options plus applicable taxes:
(a) 5% of the then outstanding amount of the Facility, or any other rate as stipulated by ICICI Bank from time to time.
OR
(b) The total interest amount outstanding as on the date of Prepayment:
I/We acknowledge that:
I/We have applied for a credit card along with the Facility that may be issued to me [Tick if applicable]
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YES
NO
I/We have not made any payment in cash, bearer cheque or kind alongwith or in connection with this
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application to the executive collecting my/our application form.
ICICI Bank shall be entitled to recall the loan/ take possession of the vehicle/assets in the event I/We
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default in complying with the obligations in relation to the Facility and also that the registration certifi
cate of vehicle referred to in the application form will be handed over to ICICI Bank within 30 days from
the date(s) of respective disbursement(s) under the Facility.
The sanction under the Facility, if and when sanctioned, shall be governed by the terms and conditions
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applicable thereto and it shall be my/our responsibility to obtain the copy and read the same.
** ICICI Bank follows defined Installment banking dates. For cases disbursed from the 1st - 15th of a particular month, the installment dates
will fall on the 1st of every month, and for cases disbursed between the 16th and 30th/31st of a particular month, the installment dates will
fall on the 15th of every month.
Accordingly, accounting reconciliations would be suitably effected at the time of payment of last EMI and surplus amount, if any, would
be refunded to the Applicant.
Name of the Applicant(s):_________________________
Signature(s):
Date: ________ Location:___________
DSE / DSA Signature ______________
DSE / DSA Name: _________________
DSE / DSA Phone No: _____________
Location: ________________________
DSE / DSA Stamp: ___________________
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Fees is non refundable

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