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eWallet Top up Issue

Fill this form, if you have tried Topping up your eWallet By NetBanking or Electronic Fund Transfer
but the Top up failed due to some reason.

I (name)
Email id
Transfered (amount)

Rs.

To Top up my OxiCash eWallet

From my

Bank A/c

To Oxigen's

Bank A/c (In case of Electronic Fund Transfer)

On Dated
 
(DD/MM/YYYY)
With Reference No
Screenshot of My Bank Statement: what is this ?
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