Application Number :

Passport Size
DSA/DSE No.:
Photograph
Channel Code : For Individual

Channel Staff Code : Customers

Not applicable for any Tag balance or
aggregate value not exceeding
Channel DSA/DSE No.: Rs.10,000 per month

ICICI BANK TAG APPLICATION FORM

PLEASE FILL IN THE DETAILS IN BLOCK LETTERS: (Fields marked with * are mandatory)

*Type of Account: Corporate Proprietor/Partner Individual Others * * Employee Code :

Date:
DD MM YYYY

CUSTOMER DETAILS

(Please fill as per the account type)

*Corporate Name:

Type of Entity: Public Ltd Society / Trust / HUF Partnership Proprietorship Private Ltd *Date of Incorporation:

*Customer Name:
First Name Middle Name Last Name
(Incase of corporate account, enter details of the contact person)

Gender (Individual): Male Female Third Gender *Date of Birth:

DD MM YYYY

Mother’s Maiden Name:

Registered with Tax Authority: Yes / No. If Yes, provide GSTIN No.____________________________________________________________________________________ PAN Number:

Unit/Branch of Service Provider: Yes No • Related Party: Yes No • Input Service Distributor: Yes No • Located in SEZ, STPI etc: Yes No

(Please provide the following details if you hold an account in ICICI bank)

ICICI Bank Account Number: ICICI Bank Customer ID:

Link your FASTag account with your ICICI Bank current or savings account for auto top up through standing instruction. Kindly visit www.icicibank.com/fastag
for more details on enabling standing instruction.

CONTACT DETAILS

(Please provide the address on which you wish to receive communications)

*Address:

*City: *State:

Country I N D I A *PIN: *Mobile:

E-mailID:

Residence Ph.No.: Office Ph.No.: (No.) Office Ph.No.: (No.)

STDCode STDCode

DRIVER DETAILS

(Details of the driver to be captured if owner is not present)

Name:

ID proof:

(PAN Card/Aadhaar Card/Passport/Voter Id/Ration Card/Driving License) ID proof No.:

 Kindly provide the below documents if your ETC Tag balance or aggregate toll transactional value exceed Rs.10,000 at any given point in time during the month.

*Corporate

Public Ltd/Private Ltd/Partnership Proprietorship

*Certificate of Incorporation/Partnership Deed/Registration certificate of the firm *PAN Card of Proprietor PAN Card Number

*PAN Card of the corporate PAN Card Number *Shop Act or other Firm Proof *Address Proof of the Proprietor

*Photo ID of signing authority *Address Proof of the Organisation

GST Registration Certificate
GST Registration Certificate *List of Directors with addresses
/Name and addresses of Partners

*Individual

Please submit ID proof and Address proof documents from the following list of valid documents

Driving License *PAN Card number Passport Voter ID Card

(Can be used as Id proof only)

*Aadhaar Card number

(with address mentioned)

*Proof of Identity Document Number: (for individual customer transactions not exceeding the aggregate sum of Rs.10,000 per month)

PAYMENT DETAILS

Payment Mode: Cheque Cash* NEFT Others__________________________________ Amount: `

(*Payment by cash is acceptable (Please Specify)
ONLY at select POS locations)
Cheque Details:

Cheque No.: UTR No.: Cheque Date:

D D M M Y Y Y Y

Bank Account No.:

Bank and Branch:

IFSC Code: Transaction ID:

(For Official use only)

ANNEXURE
Charges applicable on ICICI Bank Tag:

PARTICULARS AMOUNT (INR)

Tag Joining Fee

Please note:
1. Tag joining fee is inclusive of GST.
2. Convenience fee will be applicable for online recharge which is charged by payment gateway service provider
3. Charges mentioned above are subject to change. Please visit www.icicibank.com for the latest changes

One – time Tag Deposit amount (Refundable):

Tag Description Tag Color Tag Deposit Threshold Amount

Class

4 Car / Jeep / Van Violet 200 200

4 TATA Ace and Similar mini Light Commercial Vehicle Violet 200 100

5 Light Commercial Vehicle/Mini Bus Orange 300 140

6 Bus 3- Axle Yellow 400 300

6 Truck 3 – Axle Yellow 500 300

7 Bus 2 – Axle /Truck 2- Axle Green 400 300

12 Tractor / Tractor with trailer / Truck 4 / 5 / 6 Axle Pink 500 300

15 Truck 7 – Axle and above Blue 500 300

16 Earth Moving / Heavy Construction Machinery Black 500 300

Note: The above mentioned Tag deposit rates would be applicable depending on your vehicle class and would be refunded to you at the time of ICICI Bank FASTag account closure. For more information about
your account and applicable rates, please visit www.icicibank.com/fastag
 FOR OFFICIAL USE ONLY:

ICICI Bank FASTag Customer Id: Application Reference Number:

Transaction Date:
DD MM YYYY
Total Amount Received: `

I confirm the form has been signed by the applicant in my presence.

I also confirm the documents provided by the applicant have been verified with the originals.
All documents scrutinized and found in order by official at Agent location

All documents completed

and submitted on: DD MM YYYY
Signature of the POS Agent Official/Bank Official

POS VSTS No.:______________________________________________

Bank Official Name and Employee Id: ______________________________

VEHICLE DETAILS

*License Plate Number/ *Vehicle Type / *ICICI Bank * Tag Deposit

funded *Mobile No. Plaza Name for monthly pass
Engine Number/Chasis Number Vehicle Class Y/N Amount

Total (`):

Total no. of tags applied for: Primary Bank for recharging the ETC Tags: ______________________________________________________
( Use annexure if more than 8)

Annexure Used: Yes No Annexure Number: (If Annexure is used for listing vehicles)

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CONSUMER RECEIPT

Customer Name:

ICICI Bank Tag

Customer ID: Application Reference Number:

Total number of tags Total ICICI Bank Total Service Tax:

applied for: Tag Fee: ` `

Total Amount uploaded on Total amount received

ICICI Bank Tag: ` from the customer: `

Point of Sale (POS) kiosk name : Location:

Date:
Employee name and signature: DD MM YYYY

• ICICI Bank FASTag is issued by ICICI Bank Ltd.

*Terms and conditions apply

• Point of Sale (POS) collect fee(s) from customers on behalf of

ICICI Bank Ltd.
Stamp of POS agency with date:
Customer Care: 1800 210 0104
 DECLARATION

I declare, confirm, and agree that:

1. I have read,understood and hereby agree to the terms and conditions as applicable to ICICI Bank FASTag as set forth on the website – www.icicibank.com/fastag which may be
amended from time to time. I understand that access to any changes/updation in terms and conditions applicable to this account/relationship would be available on the website
only and I shall agree to abide by the same.

2. All the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and I
have not withheld any information. I agree and undertake to provide any further information that ICICI Bank/its Group Companies may require from time to time

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

4. I authorize ICICI Bank/its Group Companies or there agents to make references and enquires which ICICI Bank/its Group Companies consider necessary in respect of or in relation
to information in this application.

5. To inform ICICI Bank & its Group Companies immediately regarding any change in any of the information provided by me in this application form and to provide any further
information that ICICI Bank & its Group Companies may require from time to time.

6. I authorize ICICI Bank/its Group Companies to exchange, share or part with all the information, data or documents relating to my application with other ICICI Group Companies/
Banks/ Financial Instruction /Credit bureaus/Agencies/Statutory Bodies or any other persons as ICICI Bank/its Group Companies may deem necessary or appropriate or as may be
required for use or processing of the said information/data by such person or ICICI Bank/its group companies and shall not hold ICICI Bank/its Group Companies liable for the
use/sharing of this information by either ICICI Bank or such third parties.

7. I authorize ICICI Bank unconditionally and irrevocably to debit the relevant fees and charges applicable to the ICICI Bank Tag (as mentioned in the “Terms and Conditions”,
“Schedule of Charges” and “Product Leaflet" ) from the funds available in my ICICI Bank Tag Account.

8. I declare that the information I have provided is accurate and complete to the best of my knowledge. I authorize ICICI Bank & its representatives to call or SMS me with reference
to my Tag and ancillary product applications. This consent will override any registration for DNC/NDNC which you may have registered.

9. I authorize ICICI Bank to unconditionally use my Aadhaar details as provided with my ICICI Bank Savings/Current Account or any other product I may have availed from ICICI Bank.

10. I have understood the offer and details of the Value Added Service provided by ICICI Bank. I am willingly subscribing to the VAS offering and promise to pay the sum payable for
availing the service.

11. I hereby give my consent to use/exchange or share my Aadhaar number, Aadhaar information for registration of client information with Exchange, KRA, CERSAI and with any other
regulatory agency of ICICI Bank which it deems fit or as per requirements of law .

Please ensure that prior to submitting the application form you have received the ICICI Bank FASTag product leaflet and have understood the:

•Schedule of Rates and Charges

•Refer www.icicibank.com for detailed Terms and Conditions

Date:
DD MM YYYY

Signature of the authorized signatory / Individual Customer Place:

--------------------------------------------------------------------------------------
How to recharge your ICICI Bank FASTag account ?
ICICI Bank FASTag can be recharged through modes like- internet banking, NEFT/RTGS, UPI, credit card, debit card, cheque, cash etc.

For online recharges:

• Visit www.icicibank.com/fastag with your username and password
• Go to Payments ® Recharge account
• Select Tag/CUG wallet recharge as applicable and choose the payment made as per your convenience
• Choose from one of the following options available
• For more details, Terms and Conditions, kindly visit www .icicibank.com/fastag

Available options Funds upload time Convenience fee#

ICICI Bank CIB and RIB Real time Free of cost

UPI Real time Free of cost

Debit card Real time 0.2%-0.85% (basis the transaction value )*

Credit card Real time 1.8% of transaction value *

Internet banking Real time 1%- 1.65% (basis the transaction value)*

NEFT As per NEFT cycle • CUG wallet recharge: Free or NEFT/RTGS charged as levied by source bank
• Tag Wallet Recharge: Rs.15 per transaction for tag level recharge

Cheque ICICI Bank - T+1 Free

Other Bank - T+4
T = time or date of transaction.

# Convenience fee is levied by the payment gateway for the services provided and not by ICICI Bank. The fee is levied against the cost of transaction and not for revenue in
the FASTag program. *Convenience fee may change basis the payment gateway selected and/or change in commercials between ICICI Bank and the payment gateway .

For offline rec harge modes

• Recharge through cash/cheque is available in selected point of sales (POS) locations. For more details, please contact the Customer Care on 1800 210 0104 or visit
www.icicibank.com/fastag