FORM A2 ANNEXURE-V

AD Code No.0200238 5560063

Application cum Declaration Bank of Baroda,Vapi Ind. Estate SSI Br. Vapi.
(to be filled by the applicant) Form No………………………………………………
Currency …………………………….Amount………
Equivalent to Rs……………………………………
(To be completed by Authorized Dealer)
Application for drawal of foreign exchange
I. Details of the applicant -
a. Name : ____________________________
b. Address : ____________________________________________
c. Account No. : _____________________
II. Details of the foreign exchange required
1. Amount (Specify currency) : ___________________
2. Purpose : __________________________________
III. I authorise you to debit my Saving Bank/Current/RFC/EEFC Account No._________________ to gether with your
charges and
* a) Issue a draft : Beneficiary's Name ________________________
Address ________________________________
* b) Effect the foreign exchange remittance directly -
1. Beneficiary's Name : _________________________________
2. Name and address of the Bank : _______________________
3. Account No. : ____________________
* c) Issue travellers cheques for _____________________________
* d) Issue foreign currency notes for _________________________
• (Strike out whichever is not applicable)
Signature of Applicant
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 USD _____________ (USD ________________________only) the
annual limit prescribed by Reserve Bank of India for the said purpose.
* 2) Foreign exchange purchased from you is for the purpose indicated above.
• (Strike out whichever is not applicable)

Signature of Applicant

Name _____________
Date :
(The purpose codes are on the reverse)
We hereby declare that all forex transactions , as my be entrusted by us to the bank from time to time will be in strict
conformity with the prevailing provisions of FEMA , 1999 at the time the transactions are put through.
I/We further declare that the undersigned has/have the authority to give this declaration and undertaking on behalf of the
firm /company

Place :- Signature of the Application

Date :- For Foreing Exchange
Application when the declaration / undertaking are signed on behalf of the firm /company

Certificate to be furnished by Authorised Dealers (Applicant's Banker)

We hereby certify that

A. the remittance has been made

In terms of authority delegated to authorised dealers vide paragraph __________ AP Dir Circular
No.

____________________________________________________________dated

or

In terms of Reserve Bank Permit No. ________________ dated ___________________

B. all the Exchange Control regulations applicable to the remittance have been complied
with.

C. documentary evidence in support of the payment has been verified.

D. payment to the beneficiary has been/will be made through______________________

______________________________________________________________________________

(Name and address of the designated bank in ACU member country)

Purpose Code as per AP Dir Series) cir No. 77 dated 13 March, 2004
S
For BANK OF BARODA

Date: ____________ Manager (FOREX)

Stamp V Vapi Ind. Estate SSI Branch

VAPI-296 195