Annexure A-1

FORM A2 and Application cum Declaration for purchase of foreign exchange under Liberalised Remittance Scheme (LRS) as amended by RBI
vide circular A..P. (DIR Series) Circular No. 106 dated June 1, 2015 for INDIAN PASSPORT HOLDER
(To be completed by the applicant in BLOCK letters)

Date: ___________________

The Branch Manager

CentrumDirect Limited
_________________ Branch

Dear Sir,

Subject: Remittance / Release of Foreign Exchange for Private Visit /Medical Treatment / Emigrations /
Overseas Education / Employment / Other purposes ___________________ (Please Specify) (Strike out
whichever is not applicable).

With reference to the above I request you to release foreign exchange for the following purpose and furnish
the following details:

1. Details of Applicant / Remitter

Applicant Name: ____________________________________________ Date of Birth: _______________

Address: _____________________________________________________________________________

_____________________________________________________________________________________

Telephone No: __________________ Mobile No.:_____________________ Email ID: ________________

Nationality: ___________________________________ Residential Status: ________________________

PAN No. _________________________________

Passport No: ___________ Date of Issue: __________Date of Expiry: _________ Place of Issue: __________

2. Details of Person on whose behalf remittance is being made under overseas education

Student Name: _________________________________________ Passport No.: _____________________

*College University: ________________________________________ Academic Year: __________________

City / Country: __________________________________ Date of Travel _____________________________

**Relationship with the remitter ___________________________

_____________________
Signature of the applicant

*copy of the letter from overseas university to be attached.

** Only family members are permitted in the case of remittance under purpose overseas education

141 | P a g e
 3. Foreign exchange amount to be released / remitted (Please provide the exact split)

Cash Currency & Amount __________________ Travellers Cheque Currency & Amount ____________

Card Currency & Amount ____________________ Draft Currency & Amount ______________________

TT Currency & Amount _____________________

Equivalent to Rs. _________________________ Equivalent to USD _______________________

Country of Travel / Remittance: __________________________ Date of Travel: ___________________

Source of Funds: __________________________________________________

In case of Demand Draf

Draft Favouring _______________________________________________________________________

In case of swif / Telegraphic transfer

Beneficiary Details:
Beneficiary Name ______________________________________________________________________
Beneficiary Address _____________________________________________________________________
Beneficiary Bank Account Number _________________________________________________________
Beneficiary Bank Name and Address _______________________________________________________
Swift Code / Routing No. _________________________________________________________________
ABA routing / BLZ / Sort Code / Bank Code: __________________________________________________
Id IBAN International: ___________________________________________________________________
Additional information to the beneficiary (if available) _________________________________________
Information to be sent with wire transfer, if any ______________________________________________
Correspondent Bank Charges: Beneficiary / Ours (Strike out whichever is not applicable)

4. Details of the remittance made / transaction effected under the LRS in the current financial
year. (April ______ March _______)

Sr. Date FCN & Equivalent to Equivalent to Name and address of AD branch/FFMC
No. Amount Rs. USD through which the transaction has
been effected

______________________
Signature of the applicant

142 | P a g e
 Declaration cum undertaking
I, the undersigned, hereby declare that the total amount of foreign exchange purchased from or remitted through, all sources in
India during the financial year as per item no. 4 of the Application, including the current transaction is within the overall limit of
USD 250,000/- (USD Dollar Two Hundred and Fifty Thousand Only), which is the limit prescribed by the Reserve Bank of India for
the said purpose and certify that the source of funds for making the said remittance belong to me and the foreign exchange shall
not be used for prohibited purposes. The transaction details of which are mentioned above does not involve, and is not designed
for the purpose of any contravention or evasion of the provisions of the FEMA, 1999 or of any Rule, Regulation, Notification,
Direction or Order made there under. I also hereby agree and undertake to provide such information /documents as will
reasonably satisfy you about this transaction in terms of this declaration. I shall be responsible and liable for any incorrect
information provided by me. I agree that in the event the transaction is cancelled or revoked by me after submitting the request,
any exchange losses incurred in this connection to be recovered from the refund amount. I further agree that once the funds
remitted by me have been transmitted by Centrum (through AD Bank)to the correspondent and/or beneficiary banks, Centrum
shall not be responsible for any delays in the disbursement of such funds including the withholding of such funds by the
correspondent and/or beneficiary bank. I agree that once funds are remitted, intermediary bank charges may be levied by
Correspondent and /or Beneficiary Banks, which may vary from Bank to Bank. I agree that in the event the transaction being
rejected by the beneficiary bank because of incorrect information submitted by me, any charges levied by the beneficiary bank
or exchange losses incurred in this connection, I will be liable to pay the same to Centrum. I further confirm that the foreign
exchange released for the above mentioned purpose will be used within 180 days of purchase. In case it is not possible to use
the foreign exchange within the period of 180 days, same will be surrendered to an authorised person I am neither a politically
Exposed Person (PEP) not related to any of the PEPs.

I enclose herewith Cash / Cheque / DD No. __________ dated. _________ drawn on

___________________________________ for Rs.___________ towards the cost of the above exchange

I understand that it is mandatory for you to collect copy of my visa before release of foreign exchange to me and keep the same
on record. In my case, the VISA will be (select whichever is applicable)
 on arrival at the concerned country ,
stamped only after the endorsement of availing exchange,
Hence, I am unable to produce copy of the visa to you. I undertake to produce my passport to you any time after my return
from trip as a proof of obtaining visa as well as undertaking the trip abroad.

______________________
Signature of the applicant
Name:

If applicant is minor

___________________________________________
Signature of the natural guardian of the applicant @

Name: ___________________________ Relationship with the Applicant: _______________________

____________________________________________________________________________________
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 issued by the Reserve Bank from time to time under the Scheme. I
have verified KYC documents in original.

Name and designation of the authorised official:

____________ _______________ ________________ _______________

Signature Date Place Stamp & seal

143 | P a g e