To,

The Branch Manager,

............... Branch,

Sub: Refund of the remaining amount on my ICICI Bank Travel Card

Dear Sir,

I would want a refund of the balance remaining on my ICICI Bank Travel Card. The details are provided below

Travel Card Number 4065 8300 0353 8463

Name JANDHYALA JAGMOHAN VIJAY
Permanent Address (as specified in the FLAT NO 304, SAI RAM SIRISAMPADA,APTS 7-1-29
Travel card application form) LEELA NAGAR, AMEERPET, HYDERABAD 500016
Date of Birth 22/12/1984
Mothers maiden name VEMULAKONDA SUBHADRA
Passport Number M7717059
Amount to be reloaded $/Eur 1508.37 $

I have provided a copy of the my passport and the front and reverse of my Travel Card

I want a refund certificate

The refund mode is (tick one).

Credited in INR to my ICICI Bank account ________________________________________________________________________________________

Credited in INR to my _____________________________________________________________ bank account : ______________________________

Funds remitted to my RFC (D) account __________________________________________________________________________________________

A demand draft in my name

0 3 0 4 2 0 1 7
Name and Signature Date

FOR OFFICE USE ONLY

Request processed by (Name and signature) Date :

Approved

Rejected Remarks :
Stamped