Pricing and Enrolment Payment Gateway CUSTOMER DETAILS Customer Type New Customer Existing Customer Name Spouse Mobile Number: LAB UIN/ CRM ID (16 Digit number available on your report/agreement) Registered Mobile Number Registered Email Address City Name of Sale Representative EDD PAYMENT DETAILS Total Amount to be deducted Payment Plan - Select -Onetime No. of Installments - Select -123456789101112131415161718192021222324252627282930313233343536 Debit Start Date Debit End Date Payment Mode E-Nach (Net Banking) E-Nach (Card) Bank - Select -Axis BankANDHRA BANKANDHRA PRAGATHI GRAMEENA BANKBank of BarodaBank Of MaharashtraBANDHAN BANK LTDCentral Bank of IndiaCITY UNION BANK LTDCANARA BANKCITI BANKDBS BANK INDIA LTDDCB BANK LTDDEUTSCHE BANK AGDHANALAXMI BANKEQUITAS SMALL FINANCE BANK LTDFEDERAL BANKHDFC BANK LTDHSBC BANKICICI BankIDBI BANKIDFC Bank LtdINDIAN BANKINDIAN OVERSEAS BANKINDUS IND Bank JANA SMALL FINANCE BANK LTDJIO PAYMENTS BANK LTDKARNATAKA BANK LTDKARNATAKA VIKAS GRAMEENA BANKKARUR VYSA BANKKotak Mahindra BankORIENTAL BANK OF COMMERCEPAYTM PAYMENTS BANK LTDPUNJAB AND SIND BANKPunjab National BankRBL BANK LTDSOUTH INDIAN BANKSTANDARD CHARTERED BANKSTATE BANK OF INDIASYNDICATE BANKTAMILNAD MERCANTILE BANK LTDTHE CATHOLIC SYRIAN BANK (CSB Bank Ltd)THE COSMOS CO-OPERATIVE BANK LTDTHE VARACHHA CO OP BANK LTDUJJIVAN SMALL FINANCE BANK LTDUNION BANK OF INDIAUNITED BANK OF INDIAUCO ENACHYES BANK Bank - Select -ANDHRA BANKAu Small Finance BankAxis BankBank of BarodaBANK OF INDIABank of MaharashtraCANARA BANKCAPITAL SMALL FINANCE BANK LTDCITI BANKDBS BANK INDIA LTDDCB BANK LTDDEUTSCHE BANK AGDHANALAXMI BANKEQUITAS SMALL FINANCE BANK LTDFEDERAL BANKHDFC BANKICICI BankIDFC FIRST BANKINDUS IND BANKJANA SMALL FINANCE BANK LTDKARNATAKA BANK LTDKotak Mahindra BankKURLA NAGARIK SAHAKARI BANK LTDPAYTM PAYMENTS BANK LTDPUNJAB NATIONAL BANKRBL BANK LTDSHIVALIK SMALL FINANCE BANK LTDSTANDARD CHARTERED BANKSTATE BANK OF INDIASOUTH INDIAN BANKTAMILNAD MERCANTILE BANK LTDTHE CATHOLIC SYRIAN BANK (CSB Bank Ltd)THE CHEMBUR NAGARIK SAHAKARI BANKTHE NATIONAL CO OP BANK LTDUJJIVAN SMALL FINANCE BANK LTDUNION BANK OF INDIAUNITED BANK OF INDIAYES BANK - Debit of amount will start after the actual date of delivery of the client.- Installment amount will be deducted on the basis of plan chosen by the client in the agreement. Refer Price Plan.- Any promos will be adjusted from last installment/installments.- Installment will be deducted by the company on 10th of every month. CAPTCHA
