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Date: DD/MM/YYYY

EXIT FORM
Registered Mobile / CIF/Account :

Bank Name: State: District:

Entity: FINO Money Mart Merchant Distributor Other’s:___________________

Reason of Exit: RCU Defaulter Audit Issue Non Performance Shop Closed/Relocated Low Commission Unsatisfactory Service
Any Others please mention: ___________________

1. PERSONAL DETAILS
Full Nam e: ........................................................................................................................................................................................................................................

Any disciplinary action taken against you while in service. Yes No

If yes, give details: ........................................................................................................................................................................................................................

Do you have any Customer complaint Pending? Yes No


If yes, give details: ........................................................................................................................................................................................................................

2. RECEIVING OF HARDWARE:
Sr. Inventory Name Returned Condition Serial Nos.
1 Y N Working Faulty
2 Y N Working Faulty
3 Y N Working Faulty
4 Y N Working Faulty
5 Y N Working Faulty
6 Y N Working Faulty
7 Y N Working Faulty
8 Y N Working Faulty
9 Y N Working Faulty

3. BANK DETAILS (For Refund Processing, if any)


Name of Account holder:…………………………….............Your Bank: ....................................................A/c No.: .................................... Branch: ...............................
IFSC Code: .................
4. Account Details:
Registered Mobile number: ................................................. Balance: ....................................
5. Deduction
Inventory Loss: Amount: ………………………………… Against (Inventory type)………………………………….
OD Limit: Amount ………………………………….
Stamp
6. DECLARATION
1. I hereby declare & authorize FINO Payments Bank to deduct the amount pertaining to my dues against my Inventory
loss/Cash In hand/ Miscellaneous as mentioned in the agreement from my security
2. I have no objection for the deduction as the same has been already conveyed to me. Authorized Signatory (with seal)
3. I state that there is no conflict of interest for the closure of agreement.
4. I acknowledge and assure that there are no transactions pertaining to Money Laundering under the Anti Money Laundering Act and
guidelines for which I can be held accountable. If any such transactions arise now or in future, I shall be held solely responsible for
it.

5. I also acknowledge and assure that in no event I have misrepresented/mislead/committed fraud for the services provided for Fino
Payments bank and if anything arises in future, I acknowledge that I shall be held solely responsible for it.
6. I declare that I have processed all the transactions till date. If any customer complains arises post my exit, I will be fully liable for the settlement of such customer complains.
7. I also declare that there is no discrepancy pertaining to my account, virtual/electronic limit given by Company/ authorized representative, and cash handed over to
Company representative/deposited in bank. Discrepancy if any shall be informed to customer care within 48 hours from date of signing of this letter.
8. I hereby confirm that I have removed/handed over the branding materials/ Certificate of the Company and any other possession of the Company and declare that will not use
any of it in future while dealing with any of customer/ parties.
9. . I hereby declare that above details furnished are true and correct to the best of my knowledge and belief and in case any of the above information is found to be false or
untrue or misleading or misrepresenting, I am aware that I shall be held liable for it.

Sales Officer Signature


6. SALES REPRESENTATIVE DECLARATION
I hereby confirm that this form was signed in my presence and I have physically seen and verified the
details.
Sales Officer Name: ………………………… Employee Code: ………………..

We thank you for your support and look forward to working with you on our future Endeavour’s
FINO Payments Bank
Registered office: ‘FINO Payments Bank Limited’, Shree Sawan Knowledge Park, Plot No. D-507, 2nd Floor MIDC Turbhe, Navi Mumbai - 400070, INDIA. Tel :( +022 - 71047000)
E-mail: care@finobank.com | Website: www.finobank.com

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