Customer Request Form
For Branch Office use only (Encircle requested SR/s)
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To, Request No.:
The Branch Head
Axis Bank Ltd.
Branch | SOL ID: Date of Request: D D M M Y Y Y Y
Customer Name:
Mobile Number: (OR) Wallet ID:
*I hereby certify that I am a customer of Axis Bank FASTag and would like to update the below mentioned details. I certify that I would provide all the necessary
documents when requested by the bank.
Change of customer details (Select all details as applicable):
Dispatch Address Document Number Mobile Number E-mail ID Vehicle Number
1. Change of Dispatch Address
*Address:
*Landmark: *State:
*City: *Pincode:
*Country: *Nationality:
2. Document Number Update
(For Minimum KYC updation require PAN Card / Passport / Driving License / Voter ID Card - for Non Axis Bank Customer) - Attach document copy with Branch Original
verified attestation
*Document Type:
*Document No.: *Document Validity Date: D D M M Y Y Y Y
3. Mobile Number Update
*Mobile Number:
4. E-mail ID Update
*E-mail ID:
5. Vehicle Number Update (RC Copy with Original Verified and Branch Attestation to be attached)
*Existing Vehicle Number (according to profile) / Chasis Number:
*Vehicle Number to be Updated:
6. Re-Issuance of FASTag - (Applicable Tag cost would be recovered from wallet balance)
*Vehicle Number:
*I confirm that I have removed and disposed the existing FASTag from my Vehicle
*(I hereby give my consent to debit my wallet with applicable Tag cost)
7. Addition of Vehicle in Existing Wallet (Applicable Tag cost, security deposit and threshold amount would be recovered from wallet balance)
*Vehicle Number:
*(I hereby give my consent to debit my wallet with applicable Tag cost, security deposit and threshold amount)
*RC Copy with original verified & branch attestation to be attached
*FASTag would be issued as per vehicle class identified from RC
8. Dispute / Chargeback
Double debit Paid by Cash Excess Charged Others
*Toll Txn. Date: *Amount: *Paza Name:
Dispute Information:
9. Closure of Wallet
*Refund Bank Account No:
*Bank IFSC Code:
*Bank Account Name: *Bank Name:
10. Tag Closure (Wallet will be active only FASTag allocated would be closed)
Vehicle Number: (OR) Tag Sequence Number
*Post Tag closure, funds will get credited in linked wallet.
11. Update CIF ID for Enabling Full KYC (Axis Bank Customers)
*Account No.: *Customer ID:
12. Any other Issue
Customer Signature
FOR BRANCH OFFICE USE ONLY
Certified that this Request Letter is complete in all respect and all relevant documents are obtained and verified mode of operation and signatures of the A/C.
The request may please be processed. The CRF has been personally submitted by the Customer. I have satisfied myself about the identity of the Customer by verifying
his / her Debit Card / KYC document and also his / her signature in Bank's records. I have done a proper due diligence for updating the records of the Customer on his
/ her request at non-base branch.
Request received date: D D M M Y Y Y Y
S. S. Number :
Request accepted by: Employee number: Signature:
ACKNOWLEDGEMENT TO CUSTOMER
Request Number: Request received date:
Employee Number:
Name of Branch Official: Signature:
