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 (To be completed by the applicant) 

I           Details of the applicant

a.      Name …………………………..

b.      Address…………………………

c.      Account No……………………..

d.      PAN No…………………………. 

II          Details of the foreign exchange required 

1.      Amount (Specify currency)………………………………

2.   Purpose                                 ……………………………….. 

III         Source of funds:                             ………………………………….  

IV        Nature of instrument

Draft…………….  

Direct remittance…………

V  Details of the remittance made under the scheme in the calendar year ………

Date                                        Amount 

VI        Details of the Beneficiary

1.      Name …………….

2.      Address ………………………………………………….

*    3.  Name and address of the bank………………………. 

*    4.  Account No…………………………………. 

(* Required only when the remittance is to be directly credited to the bank account of the beneficiary)

This is to authorize you to debit my account and effect the foreign exchange remittance/issue a draft as detailed above. (strike out whichever is not applicable). 

Declaration

 I, ………………. ……, hereby declare that the total amount of foreign exchange

          (Name)

exchange purchased from or remitted through, all sources in India during the current calendar year as per item No. V of the Application, is within the limit of USD 25,000/- (US Dollar Twenty Five Thousand only), which is the limit prescribed by the Reserve Bank for the purpose and certify that the source of funds for making the said remittance belongs to me and will not be used for prohibited purposes.

Signature of the applicant

(Name) 

Certificate by the authorised dealer

This is to certify that the remittance is not being made by/ to ineligible entities and that the remittance is in conformity with the instructions contained in Reserve Bank A.P.(DIR Series) Circular No.64  dated   February 4,  2004.

Name and designation of the authorized official: 

Place:                                                                                           Signature

Date:                                                                     Stamp and seal of the AD branch