FORM-A 2 MFX No. 004324, Application Cum Declaration Form (To be completed by the applicant) Carag. Day (Ferpaymet ct tn pert ancrantarcas cong homey te) MBO. TYP@ : MT Qo. ‘Seq. No. ‘AD Cove No, 0000482 NagpurNain Branch Fm No, o4s2 (To be filled by the Authorized Dealer) coureney Amount @ Evento INR (oven Atored Dsl) Application For remittance Abroad commission NR st inr TCSINR We Name ove ———— PAN No, : Aout __ ‘Address : ine PN oto No.: Ena, ‘Authorised $81 Negpur Main Branch to debit my our Saving Bank / Curent / RFC / EFC Alc No. ‘together with thelr charges IF No. =, ‘Signature of Applicant AND = a) Issue a draft: YES/NO *b) Relationship with sender : *c) Effect the foreign exchange remittance (TT) directly - 1) Beneficany’s Name. Address Peseta See an, 2) Name and address of the bank ‘Swit Code : —— 3) Account NoJIBAN, oe 4) Routing / ABA/ BSB NoJTransit Code/insitution Code 5) Inter Mediary / Correspondent Bank : SWIFT. NAME 8) intermediary / Correspondent Bank charges type : SHARING / OURS: ‘Se No] Whether under LR.S. Purpose Gode | Description (yesmNo) [Aspermenmen (Reiter shoul put ak (/ ) agent an agprepit usp code. n casa / Cot iy, he AD bank should be contd) 7) Other details: Student's Name (for education) ' Student's 1D No/Ret. No. += (Sirike out whichever is not applicable) ‘Signature of the Applicant — pets) Name; Fast PDF ScannerDISCLAIMER CLAUSE “VWerequestyouto effect the above mentioned remittance through Swift /mall/ posta service /telegraph cable / otherwise entirely at my sk and responsibilty and on the distinct understanding that no lability ‘whatsoever to be the Bank for any loss, injury or damage ariing or resulting from delay intranemisson, delivery oF non-deltvery of the relative message / instrument and delay In payment / non-payment to the beneficiary concemed or for any mistake, omission or error In transmission or delivery thereof or in de-cipherng the message for any cause whatsoever o roms misinterpretatlon when received. /Weflly ‘understand and realize that you wil make use of one / some of your Foreign Ofices / Correspondent Banks / ‘Agents or sub-Agents and we shall not hold you llable or responsible In any manner for any errors, netligence, suspension or defaut of any of them orfor any failure toldentity the payee or ary mis payments by any of them nor shall we hold you lable for any suspension of the means of transmission or any Impostionof any censorship, exchange controlor other restriction” ‘Signature of Applicant Declaration (Under FEMA 1988) 1 Han i (Name), hereby dectare that the total amount offoreign exchange purchased from orremited trough, al sources in inca during the financial year including this application is within the overall of the Liberalized Remittance Scheme Prescribed by the Reserve Bank of India and cerity thatthe sourca of funds for making the said remittance belongs to me and the foreign exchange willnot be used for prohibited purposes. Details of the remittances madeftransactions effected under the Liberalized Remittance ‘Scheme in the current financial year(April-March) ‘Name and address of AD DraniVFFMC through which the 2. # The total amount of foreign exchange purchased from or remitted through all sources in india ‘during this calender year including this application is within USD (usd . the annual limit prescribed by Reserve BankofIndia forthe sald purpose. 3 # Foreign exchange purchased from youls forthe purpose indicated above. # (Strike outwhicheverisnot applicable) ‘Signature of applicant (Name) Date : Certificate by the Authorized Dealer ‘This is to certy that the remittance is not being made byfo ineligible entities and that the remittance isin conformity with the Instructions issued by the Reserve Bank from time to time under the Scheme, ‘Name and designation of the authorized official: ‘Stamp and seal ‘Signature: Date : Fast PDF ScannerWe hereby deciare that the transaction (s) the details of which are specifically mentioned inthe ‘Schedule hereunder does not involve andisnot designed for the purpose of any contravention or evasion of the provisions of the aforesald Act or of any rule, regulation, notification, declaration or ‘ordermade thereunder. Wo also hereby agree and undertake to give such information / documents, before the Bank undertakes the transaction(s) and as may be required from time to time as will reasonably satisfy ‘you about the transaction(s)in terms ofthe above declaration, We also understand that if We refuse to comply with any such requirement or make unsatisfactory compliance therewith, the Bank shall refuse in writing to undertake the transaction and shall if it has reason to believe | that any contravention / evasicn: is contemplated by me/us reportthe | matter to Reserve Bankoflndia, 24 WWie further declare that the undersigned has/have the authority to give this declaration and undertaking on behalf of the firrvcompany. —_——____ ‘Signature of the applicant Place : For Foreign Exchange Date: + Applicable when the declaration / undertaking Is signed on behalf of the fm / company SCHEDULE Nature / Purpose of Foreign Exchange transaction, Fast PDF ScannerTransaction Ref. No. ............ NOTICE This is to inform all our esteemed customer/remitters that in compliance with US OFAC (United states Office of Foreign Assets Control) requirements, It has been decided to scan all out-going SWIFT messages by OFAC filter solution for banned entities w.e.f. 06/ 11/2010 at our office at Global Markets Unit, Kolkata. Consequently, some of the US and Nassau-bound meessages may be blocked by the above filter solution if it contains entities matching exactly or partially with the banned entity lists provided by US Treasury Authori- ties from time to time and result in non / delayed transmissioin of such messages. Accord- ingly, all concerned are hereby requested to provide contact details in the application form to enable us to immediately contact and get clarifications in the matter. Further, this may also be noted that, subesequent to our release, based on the documents / clarifications provided by customer, the message / transaction are aslo liable to be blocked / rejected at US Offices / OFAC Authority. Though, the Bank will take all necessary / steps for timely transmission of messages, it will not be held responsible for any such non/delayed-transmission of messages, it will not be held responsible for any such non / delayed-transmission of messages. We solocit co-operation from all our valued customers in this regard. Customer Signature Fast PDF Scanner