Customer Request Letter cum Form A2 (for release of foreign exchange for travel purpose)

Date:
The Branch Head
ICICI Bank Limited
…………….. Branch
_________________
Dear Sir/Madam,

I request you to release foreign exchange as per details furnished by me in form A2(on reverse side of document).
Further additional details are:
1. I am traveling to ___________________(name of country) on __________________(Date of travel)
2. Passport Details: Passport No #strPassportNo issued on______ at (Place of Issue)_______ valid upto _
3. My occupation is :________________
4. Expected date of return __________________ (Probable date of returning from traveling country)
5. PAN number (mandatory if the transaction amount is Rs.50,000 and above):________________.
Customer declaration:

1. I am traveling abroad for the purpose as indicated in form A2. The visa/ tickets for travel to the said countries is in my possession/ been cleared and is being allotted to me.
2. 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 Authorised 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 extant regulations of RBI 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 60 days of the release of foreign exchange to me. I hereby declare that the funds provided by me for purchase of foreign exchange are from legitimate sources and are not in contravention of any law for the time being in force in India.
3. Status as a PEP(Politically Exposed Person): (Yes / No){strike out which is not applicable}

Name and Signature #strApplicantNameSign Contact No.- #strContactNo
(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:

Referrer Employee Name - Referrer Employee No.-

Date: