To
COSMO FERRITES LIMITED
30, Community Centre, Saket
New Delhi - 110017
1.	Name of Sole / First Holder
2.	Folio No. / Client ID
3.	DP. ID ( for Demat Shares )
4.	Name of Bank & Address
5.	9 Digit Code number of the bank & branch appearing on the MICR cheque issued by the bank. (Please send a photocopy of the cancelled cheque issued by bank for verifying the accuracy of the code no.)
6.	Account type ( SB account / Current Account / Cash credit account with code 10/11/13.)
7.	Account No.
I / We declare that the particulars given above are correct and complete, and if the transaction is delayed or not affected at all for reasons of incomplete or incorrect information or for sufficient response or for any other reason whatsoever, I / We would not hold company responsible.
I / We have also noted that this facility is presently being offered only to the shareholders having bank accounts at specific cities. However, we agree to be included in the Electronic Clearing Service ( ECS ) as and when our city is specified, if not already specified in this regard
		Bank's Stamp & Signature
(Signature of Shareholder)		Date
( Please get the above particulars verified by bank )