IHMCL

UCIC :

Registration/Chassis No :

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Customer Details

CIF No:

First Name:

Middle Name:

Last Name:

Address Line 1:

Address Line 2:

Address Line 3:

Address Line 4:

Post Code:

Country:

Email Address:

Mobile Number:

Identification Number:

Id Issue Date:

Id Issue Place:

Id Type:

Identification Expiry Date:

Date of Birth:

Gender Code:

Vehicle Details

Bank Id:

Tag Id:

Tag Status:

Vehicle Class:

Exception Code:

TID:

Issue Date:

Registration No:

Security ₹:

Min Balance Charge ₹:

Commercial: Yes No

Issuance Amount ₹ :

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Subscribe Auto-Recharge :

Auto Recharge Amount ₹ :

Link to existing tag A/C with IDFC :

Old Vehicle Registration/Chassis No :

Disclaimer

The customer details as per bank account would be considered for any future purpose related to FASTAG

User Consent

I declare, confirm, and agree that:

1.I have understood and here by mentioned on agree to the Terms and Conditions as applicable to the IDFC FIRST Bank Tag as the website www.idfcfirstbank.com. I understand that access to any changes/updates in the Terms and Conditions and Schedule of Charges applicable to the IDFC FIRST Bank Tag would be available on www.idfcfirstbank.com only and I hereby agree that I shall keep myself updated about any changes to these Terms and Conditions and Schedule of Charges as updated on www.idfcfirstbank.com from time to time.

2. I understand that IDFC FIRST Bank Limited (“IDFC FIRST Bank”) reserves the right to reject my application without providing any reason. I agree and understand that IDFC FIRST Bank and its Group Companies reserve the right to retain the application forms, and the documents provided herewith and will not return the same to me.

3. I authorize IDFC FIRST Bank/its Group Companies or there agents to make references and enquires which IDFC FIRST Bank/its Group Companies consider necessary in respect of or in relation to information in this application Signature of the authorized signatory/Individual Customer.

4. I authorize IDFC FIRST Bank unconditionally and irrevocably to debit the relevant fees and charges applicable to the IDFC FIRST Bank Tag (as mentioned in the Terms and Conditions, Schedule of Charges from the funds available in my IDFC FIRST Bank Tag account. I further give consent to debit my IDFC FIRST Bank account to auto top up my Fastag based on the confirmation given while linking my tag to IDFC FIRST Bank account

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