(Applicant Copy 1) (TO BE HANDED OVER TO DEPOSITOR FOR RECORD)

(Applicant Copy 2) (TO BE HANDED OVER TO DEPOSITOR FOR RECORD)

(Bank's Copy) (TO BE RETAINED BY THE RECEIVING BRANCH)

Birla Institute of Technology & Science, Pilani Birla Institute of Technology & Science, Pilani Birla Institute of Technology & Science, Pilani PAN Number: AAATB2599R PAN Number: AAATB2599R PAN Number: AAATB2599R

Name of branch: Date of Deposit:

: _____________________ : ______________ (DD/MM/YY)

Name of branch: Date of Deposit:

: _____________________ : ______________ (DD/MM/YY)

Name of branch: Date of Deposit:

: _____________________ : ______________ (DD/MM/YY)

(to be treated by Applicant as fee receipt) Account to be credited 1. Institution Name 2. Applicant Name : : :

(to be treated by Applicant as fee receipt) Account to be credited 1. Institution Name 2. Applicant Name : : :

(to be treated by Applicant as fee receipt) Account to be credited 1. Institution Name 2. Applicant Name : : :

0036SLFEECOL FCBITS Kartikeya 500186 2013 BITSAT 1775/-

0036SLFEECOL FCBITS Kartikeya 500186 2013 BITSAT 1775/-

0036SLFEECOL FCBITS Kartikeya 500186 2013 BITSAT 1775/-

3. Roll no/ Application No. : 4. Class/ Year (BITSAT) 5. Section/ Course 6. Amount ( ) : : :

3. Roll no/ Application No. : 4. Class/ Year (BITSAT) 5. Section/ Course 6. Amount ( ) : : :

3. Roll no/ Application No. : 4. Class/ Year (BITSAT) 5. Section/ Course 6. Amount ( ) : : :

7. Amount in words

: Rs. One thousand Seven Hundred and Seventy five rupees only. Amount

7. Amount in words

: Rs. One thousand Seven Hundred and Seventy five rupees only. Amount

7. Amount in words

: Rs. One thousand Seven Hundred and Seventy five rupees only. Amount

Cash Details: Denomination 1000 * 500 * 100 * 50 * 20 * 10 * 5* Coins Total No. of notes/coins

Cash Details: Denomination 1000 * 500 * 100 * 50 * 20 * 10 * 5* Coins Total No. of notes/coins

Cash Details: Denomination 1000 * 500 * 100 * 50 * 20 * 10 * 5* Coins Total No. of notes/coins

Branch Transaction ID:____________________

(This field is Mandatory)

Branch Transaction ID:____________________

(This field is Mandatory)

Branch Transaction ID:____________________

(This field is Mandatory)

__________________ Signature & Stamp ICICI Bank Ltd

__________________ Signature of Depositor

__________________ Signature & Stamp ICICI Bank Ltd

__________________ Signature of Depositor

__________________ Signature & Stamp ICICI Bank Ltd

__________________ Signature of Depositor