Amount FORM A.1.

Serial No
remitted (For import payments only) (for use of Reserve Bank of in
Currency Amount A.D.Code No.
Equivalent ot Rupees (Application fo Remittance in Foreign currency) FormNo
(To be completed by authorised dealer) (To be filled by authoris

I/We wish to purchase

(Name of currency) (Amount in words)

through STATE BANK OF INDIA, COMMERCIAL BRANCH, RAJAPALAYAM

(Name and address of the authorised dealer)

(Name and address of the beneficiary of the remittance)

imports into india detailed below:
Details of goods inported or to be importd into india

Section : import Licence/Open General Licence particulars

O.G.L /
NUMBER PART SCHEDULE SERIAL NUMB

import Licence Date of issue Date of expiry

Amount to be
Month Face value of

Month
Prefixes Licence No. Suffixes

Date
endorsed (in

year

year
Date

Licence
1 2 1 2 3 4 5 Rs.) @

@ Actual amount endoresed in rupees against each licence involved, should be stared under this column.
Note: If more than one licence is involved particulars of all licences should be furnished. If the space is inadequate a separate
statement may be atttached. The amount utilised against each licence should invariably be indicated.

Section: B Import Particulars

Invoice Details Mode of
Terms BTN Country Country from shipment (air,
Quantity Description of
No. and (c.i.f.f.o Classficat of origin which goods sea post, rail,
Currency Amount of goods goods
ion of goods are consigned river, transport
date .b.c&f
etc.,) etc.,)

Section: C Other particulars

1 Details of forward purchase contract if any,
booked against the import (No. & date of contract) (Currency and Amount of contract)

2 If remittance to be made is less than invoice value reasons

therefore (i.e. part remittance, instalment etc.,

I/We hereby declare that the statements made by me/us on this form are true and that I/We have not applied for an authorisation
through any other Bank.

I/We declare and also understand that the foreign exchange to be aquired by me/us pursuant to this appliction shall be used by
me/us only for the purposse for which it is acquired and that the conditions subject to which the exchange is granted will be complied
with

Name of Applicant(s) Nationality of Applicant(s)

Address of Applicant(s)

Date: Signature of Applicant(s)

Note: For remittance covering Intermediary trade Form A 2 should be used

 Note: For remittance covering Intermediary trade Form A 2 should be used

Declaration to be furnished by Applicant(s)

I/We declare that

(a) the goods to which the application relates have been* imported into India on my / our account
will be
(b) the Import is on behalf of @
( c )the invoice value of the goods which is declared on this form is the real value of the goods importwed* into India

to be imported
If the import I/We attach the relative customs - stamped Exchange Control copy of Entry *
has been made post parcel wrapper (for imports by post) *
or
If the import I/We undertake to produce within three months to the authorised dealer the relative Customs-stamped Exchange
is to be made Control copy of Bill of Entry *
Post parcel wrapper, (for imports by post) *

*Strike out Item not applicable.

@ Where the import is on behalf of Central/State Government Department or a Company owned by Central/State Government
statutory Corporation, Local Body, etc; the Name of the Government Department, Corporation, etc; should be stated.

Signature of Applicant (s)

Date

Space for comments of the authorised dealer while forwarding the application to the Reserve Bank of India for approval (Reference to
Exchange Control Manual paragraph A.D. circular in terms of which the reference is made should invariably be cited if and remittance
application on account of the same import was referred to the Reserve Bank earlier reference to the last correspondence / approval
should also be cited)

Date (Stamp and Signature of authorised dealer)

Certificate to be furnished by Authorised Dealer (Importers Banker)

We hereby certify that

(a) this payment is
Put a (i) 0 as advance remittance
tick (V) (ii) 0 in retirement of bill under Letter of Credit opened through us.
in the (iii) 0 against documents received through our medium for collection
relevant (iv) 0 on account of Documents received by the applicant(s) against undertaking furnished by the latter to submit
block Customs stamped Exchange Control copy of Bill of Entry/Post parcel wrapper within three months.
(v) 0 on account of Documents received by the applicant(s) against undertaking furnished by the latter to submit
Customs stamped Exchange Control copy of Bill of Entry/Post parcel wrapper within three months.
(vi) 0
(and other case to explained)
(b) all the Exchange Control regulations applicable to the remittance have been complies with
( c) the payment to the suppliers of the goods has been * made through
will be * (Name and address of the foreign bank)

We also certify/undertake that the relevant Customs - stamped Exchange Control copy of Bill of Entry or post parcel wrapper
* shall be verified by us within three months (vide certificate a (ii) and (iii) above )
* has been verified. (vide certificate a (V) above
* shall be obtained from the applicant(s) and forwarded to the Reserver Bank within three months (vide certificate a(i) and
(vi) above)

* Strike out item not applicable

Date (Stamp and Signature of authorised dealer)
eserve Bank of india)

filled by authorised dealer)

for payment to)

in payment of

SERIAL NUMBER

Balance outstanding
on the licence ater the
remittance

separate

Date of shipment(if
not known
approximate date)

(Balance under the

contract)

horisation

used by

Applicant(s)
 and

nment

dealer)

ign bank)
dealer)