The _________ Manager,
_________ Bank,
__________________
Subject: Issue of Loose Cheque in my/our Current Account no. _________
Sir,
Please issue me/us a Loose Cheque in my/ our Current Account no. _________ in this connection I undertaking & declare as under:
1. That I _______.
Thanking You,
Yours Faithfully
Signature: _________
Name & Address: _________
Contact No.: _________