To, The Branch Manager, ...............

Branch, Sub: Reload of ICICI Bank Travel Card Dear Sir, I would want to reload my ICICI Bank Travel Card. The details are provided below

Travel Card Number Name Permanent Address (as specified in the Travel card application form) Date of Birth Mothers maiden name Passport Number Amount to be reloaded $/Eur

I have provided a copy of the my passport, A2 form, PAN Card. and have and the front and reverse of my Travel Card I undertake that the usage of this card will be in accordance with the Exchange Control Regulations of the Reserve Bank of India from time to time and the Foreign Exchange Management Act of 1999.

Name and Signature

Date

FOR OFFICE USE ONLY

Request processed by (Name and signature) Approved Rejected Stamped

Date :

Remarks :

FORM A2
Application cum Declaration (To be completed by the applicant) Application for drawal of foreign exchange I. a. b. Details of the applicant Name : Address : City : State : c. d. II. 1. 2. Account No. : Estimated date of return : Details of the foreign exchange required Amount (Specify currency) : Purpose Pay Order /DD No.___________________dated_________________drawn on ICICI BANK LTD. for Rs.____________________________________ Kindly.... * a) Issue a draft : Beneficiary's Name : Address City : State : * b) 1. 2. Effect the foreign exchange remittance directly Beneficiary's Name : Name and address of the Bank : City : State : 3. Account No. : * c) Issue travelers cheques for : * d) Issue foreign currency notes for : * e) Issue ICICI Bank Travel Card for : (Strike out whichever is not applicable) PIN Code : PIN Code : PIN Code : Mr./Ms.

III. I authorize you to debit my Saving Bank/Current/RFC/EEFC Account No._________________ together with your charges / I enclose herewith Cheque/

Signature Declaration (Under FEMA 1999) I, _________________________ declare that * 1) The total amount of foreign exchange purchased from or remitted through, all sources in India during this calendar year including this application is within _____________(__________________________________________________________________only) the annual limit prescribed by Reserve Bank of India for the said purpose. * Date: 2) Foreign exchange purchased from you is for the purpose indicated above. (Strike out whichever is not applicable) Signature Name ______________________

FOR OFFICE USE ONLY

AD Code No. _________________ Form No._________________ Currency_____________ Amount_______________ Equivalent to Rs.___________ (To be filled in by Authorized Dealer)

Ads should put a tick ([) against an appropriate purpose code. (In case of doubt/difficulty, consult customer/RBI.)

P. T. O.

CUSTOMER REQUEST LETTER

To, The Manager, ICICI Bank Ltd, ....... Branch,

Date:

Dear Sir/Madam, I request you to release foreign exchange as per following details for travel to ______________________ for the purpose mentioned below. Currency Amount required in Currency Notes Travelers Cheques ICICI Bank Travel Card

Leisure Travel

Business Travel

Medical Treatment

Maintenance expense of patient/accompanying attendant

Employment

Emigration

Studies Abroad

Cultural Tours

*Please tick mark in the appropriate purpose column. Passport Details: a) Passport No. : c) Place of Issue : b) Date of Issue : d) Passport valid up to :

I will be leaving the country on ______________and returning on ____________. a) I authorize you to debit my Savings A/c No___________________ with _________ Branch for the INR equivalent of the foreign exchange released and charges, if any. b) I enclose herewith Cheque/Pay Order/DD No. ______________ dated __________ drawn on ICICI Bank Ltd. for Rs._______________. c) I agree to pay Rs. ____________in cash for the same. (Applicable only if INR equivalent of foreign exchange availed for a single visit is Rs 50000/- or below) *Please tick the appropriate option. I hereby declare that the aggregate value of foreign exchange purchased by me, including this particular transaction, during the last 30 days, including the present date, either from ICICI Bank or from any other Authorized Dealer, by making payment in INR currency notes does not exceed Rs.50,000. I hereby declare that the above details are true and correct and that the total amount of foreign exchange purchased from or remitted through, all sources in India including this application does not exceed the limit prescribed by Reserve Bank of India for the purpose indicated above. I undertake that the usage of the same by me will be in accordance with the Exchange Control Regulations of the Reserve Bank of India and the applicable laws in force from time to time. I state and agree that in the event I do not travel as aforesaid, I shall surrender the availed foreign exchange to ICICI Bank within 180 days of the release of foreign exchange to me. I confirm that I have received the above-mentioned Currency / Travelers Cheques/Travel Card on .. Name and Signature of Customer ________________________ Contact No. For Office UseI hereby confirm that the FES transaction as mentioned above is in compliance with the requirements of the circular Ref No. Signature & Account no of the customer verified by: Employee Name Date: Employee No.-

P. T. O.

BASIC TRAVEL QUOTA FORM

To, The Manager, ICICI Bank Ltd, ....... Branch,

Date:

Sub: Release of Foreign Exchange for Travel Abroad under Basic Travel Quota (BTQ) Dear Sir, I hereby request you to release foreign exchange for travel under BASIC TRAVEL QUOTA (BTQ) vide RBI A.P (DIR series) Circular No.51 dated Nov. 18, 2002 as per details mentioned below for travel to ______________________________: Total Foreign Exchange Requirement Currency Amount required in Currency Notes (FCN) Travelers Cheques (TC) ICICI Bank Travel Card

Passport Details: a) Passport No. : c) Place of Issue : Details of foreign exchange availed in this financial year: Amount Availed _______________________ Tcs + ______________________ FCNs+ _______________________ Travel Card Following are enclosed: a) Passport b) Visa c) Ticket d) Cheque/PO/Debit Advise/Cash I hereby declare that the aggregate value of foreign exchange purchased by me, including this particular transaction, during the last 30 days, including the present date, either from ICICI Bank or from any other Authorized Dealer, by making payment in INR currency notes does not exceed Rs.50,000. I undertake that the usage of the same by me will be in accordance with the Exchange Control Regulations of the Reserve Bank of India and the applicable laws in force from time to time. I state and agree that in the event I do not travel as aforesaid, I shall surrender the availed foreign ex-change to ICICI Bank within 180 days of the release of foreign exchange to me. Name and Signature : Contact No. b) Date of Issue : d) Passport valid up to :

(Customer) ___________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________

FOR OFFICE USE I hereby confirm that the FES transaction as mentioned above is in compliance with the requirements of the circular Ref No.................. Signature & Account no of the customer verified by: Employee Name : Employee No. : Date :