Online Payment Form

[ Note :   *   fields are mandatory ]
Account Assigned from*
Name of Bank or Financial Institution who has assigned (Transferred /Sold) a set of accounts.
Assignors Account/Card No*
Phoenix Contract No*
Phoenix assigns contract number to each account to be used for all communication with Phoenix.
Name of Account Holder
Trust / Payee Name
Assignor has transferred account to a trust, wherein Phoenix ARC Private Limited is Trustee.
Email ID*
Mobile Number*
Landline Number
I would like to pay Rs.*

I have read and understood all terms and conditions and agree to the same. I have verified the information stated above and confirm that the same is correct.