How to complete your payment

We will only accept one payment per payment reference. To make multiple payments, please repeat the process
to create a new payment reference number.

Payment reference Currency Amount to be paid

ECAUC51108538044 INR 8,895.00

This quote can only be used for one (1) payment is valid until 20/12/2024 08:12:53 PST

Print and complete the attached ICICI form

1 You must complete your payment in person at an ICICI Bank branch. You can use your ICICI Bank
Account or any other domestic bank account (other than ICICI Bank) for resident Indians. To
complete the form, please use the instructions below:
• Section I: If you are an ICICI Bank account holder, please complete this section

• Section II: If source of funds is a Education Loan, provide all requested loan disbursement details

• Section III: This section does not need to be completed, all details are available with ICICI Bank

• Section IV: If your payment is processed from a ICICI Bank NRO account, please complete this section

• Section V: If you do not hold an account with ICICI Bank, please complete this section

2 Visit an ICICI Bank branch to complete your payment

1. Locate a Forex enabled ICICI Bank branch near you
2. If you are a Non-ICICI account holder you must transfer funds to the ICICI Bank pooled account via
NEFT or RTGS before visiting a branch (this is not applicable if you will be using an ICICI Bank Account):
• Beneficiary: Outward Remittance Pool Account
• Account Number: 0035SLORCBPC
• IFSC Code: ICIC0000035
3. Bring the below with you to your local ICICI bank branch to complete your transaction:
• A completed Retail Outward Remittance Application – A2 cum LRS Declaration
• Proof of identity and address, either a Passport, Drivers License, Voter ID, Letter from the National
Population Register OR Job Card issued by NREGA and signed by the State Government Office
• Your PAN card
• A copy of your Sanction/Disbursement letter (if your fees are being funded by a loan)

Please note: TCS may be levied by ICICI over and above the payment instruction amount as per regulation
and you will be required to pay this while completing your transaction.

Do you have a question about completing your payment? Please contact ICICI directly:
Phone: Toll Free: 1800 1080 or Non Toll Free: 91-40-3099 8025
Email: nri@icicibank.com

3 Track your payment as it is delivered University of Calgary

With the help of Convera, your payment will arrive
at your institution in 2-3 business days.
Track your payment using the link below.

students.convera.com/#!/tracking

© Western Union Holdings Inc. In Canada, services are provided by Convera Canada ULC.

V-22-0174-2022-09
 Form A2 - Retail Outward Remittance Application
(For payments other than imports and remittances covering intermediary trade)
I. Applicant Details :
Are you an ICICI Bank Account Holder  YES  NO
Your ICICI Bank Account Number
Applicant’s Name
Applicant’s PAN, Mobile No, and e-mail ID
(* PAN is mandatory for all resident customers). Please fill up Annexure - I if you are Non-resident Indian (NRI) / Annexure - II if you do not have an account with ICICI Bank (Refer Page No. 3)

II. Wire Transfer (TT) Details :

Remittance Currency CAD ICICI Bank Charges & GST# Inclusive

Remittance Amount in INR# 8,895.00

Purpose Code and Description S1107 – Studies Abroad

Convera Reference Number ECAUC51108538044

Ultimate Service Provider Country
Student Name and ID (if any) Ankita .
University Name University of Calgary
Source of Funds  Personal Savings  Education Loan

Education Loan Availed from (if any)  ICICI Bank  Other Bank (Please specify):

Education Loan Amount Disbursed (if any) INR Loan Disbursement Date
# The applicable TCS will be deducted in addition to the Remittance Amount in INR.

III. Beneficiary Details :

Beneficiary Name Convera Canada ULC

Beneficiary Complete Address & Country 1 Toronto Street, Suite 800, Toronto, Ontario M5C 2V6

Beneficiary Account Number or IBAN

Beneficiary Bank SWIFT Code and Name
Need not to be filled/printed, Beneficiary Account/IBAN/Beneficiary Bank Swift Code & Name, etc. details are available
Beneficiary Bank Address & Country with ICICI Bank.
Transit/BSB/SORT code (as applicable)
Correspondent Bank SWIFT Code and Name

IV. To be filled only for Remittance from NRO Account (Annexure – I)

S.N. Source of Funds in NRO Account Amount (INR)
1
2
3

V. Details of Non - ICICI Bank Account Holder (Annexure – II) ( Applicable for residents only)
Applicant’s Name

Applicant’s Complete
Address City Name PIN Code State Name
Residential Status Resident Indian Gender(M/F/O) Date of Birth

Officially Valid  Aadhaar  Passport  Driving License  Voter  Letter of National  NREGA Job
Document (OVD) ID Population Register Card
Occupation  Salaried  Self-employed  Professional  Dependent  Retired  Others:

Annual Income  NIL  Upto 5  5-10 Lakh  10-20  20-35  35-50  Above 50
Lakh Lakh Lakh Lakh Lakh
Note: Provide details of Savings Bank Account from where funds will be transferred to ICICI Bank pool A/C
Bank Name Bank IFSC Code Savings Bank Account Number

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 VI. Declaration under FEMA, 1999

 I hereby declare that the total amount of foreign exchange purchased from or remitted through all sources in India during this financial year including this
application is within the overall limit of the Liberalized Remittance Scheme prescribed by the Reserve Bank of India and certify that the source of funds for
making the said remittance belongs to me and the foreign exchange will not be used for prohibited purposes (as mentioned in the terms and conditions
given in ǪR Code below).
 Foreign exchange purchased from or remitted from ICICI Bank (the Bank) is for the purpose indicated above.
 I confirm that I am a Resident Indian as defined under the FEMA, 1999 and as amended from time to time. I undertake to notify the Bank to re-designate
my account to NRO in the event of change in my residential status.
Details of remittance made under the Liberalised Remittance Scheme in the current financial year (April to March 20____, 20____)

SN Date Amount Name and Address of AD Branch / FFMC through which the transaction has been effected
1
2
3 Please add a separate sheet for more transactions.

VII. Debit Authority and confirmation on applicable terms & conditions

 I hereby authorize the Bank to debit my ICICI Bank account to effect the transaction of foreign exchange with applicable charges & taxes as mentioned on
the website www.icicibank.com. I authorize ICICI Bank to debit my account later towards recovery of TCS, (if applicable).
 As a Resident Indian, I hereby declare and confirm that the beneficiary of the above transaction is not a person resident in India.
 I confirm that I have read and understood all the terms and conditions given in QR Code or as mentioned in the link given below OR
https://www.icicibank.com/personal-banking/accounts/outward-remittance/download-form
I confirm that the declarations and statements stated by me in this form are true and correct to the best of my knowledge and belief.

Date Signature of Remitter / Guardian in case of Minor/ Mandate Holder

Scan QR and Read T&C
-------------------------------------------------------------------------------------------------------------
For Office Use only (to be filled for all transactions)

Transaction Reference Number

• I certify that I have verified the customer’s signature as per Bank records and retained the originals of all the scanned documents and forms submitted by the
remitter for the above transaction.
• I also certify that in case of LRS, 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.
Photo ID verification Photo ID is available and clear
(applicable only if transaction is requested by an ICICI Bank Account Holder, not
applicable for non-account holders) Photo ID is either not available or not clear

Transaction request verified by Meeting the customer at the Branch

(applicable only if amount is more than INR 10 Lakh)
Calling the customer on the registered contact number
Employee Name :
Employee ID :
Employee detail who has verified the transaction request by meeting or
Designation :
calling the customer
Department :
Signature : ______________________________
Name of Bank Official Employee ID Date Employee Signature & Branch Stamp

-------------------------------------------------------------------------------------------------------------
For Office Use only (To be filled only for Non Account Holders of ICICI Bank)

• I confirm having met ______________________________________________________ at the Branch / other location (specify).

• Further, I confirm the below details and have verified the copies of KYC documents (as mentioned above) with the originals produced by the
applicant and that the applicant has signed the documents in my presence.
(If the remittance is by way of accepting cash deposit then the amount should not exceed INR 50,000/-)

Name of bank official Employee ID Date Employee Signature & Branch Stamp

Bank official initiating

transaction

BM/BOM authorizing KYC

certification

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