I/We wish to purchase/transfer ____________________________________________________________through                                                               (Name of currency and amount in words)________________________________________________________________________________ for payment to                           (Name and address of Authorised Dealer)______________________________________________________ by remitting the amount / by credit to the ac-                  (Name and address of the beneficiary)count of_________________________________________________________________________________for the(Full title of the account & country of non-resident bank and name of AD with whom account is maintained)purpose indicated below:(Remitter should put a tick (ü ) against an appropriate purpose code. In case of doubt/difficulty,consult your banker.)

    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 understand that the foreign exchange to be acquired / payment to be ade by me /us pursuant to this application shall be used / made by me / us only for the purpose for which it is acquired / to be made and that the conditions subject to which the exchange/permission is granted will be complied with.

    I/We desire to travel to __________via___________for the purpose of___________________ Passage has beenbooked through_________________________________________________                               (Name of airline/shipping co.or passage agent)____________________The date of departure is ______________The exchange is required in the form of

Name of Applicant (s) ____________________________ Nationality of Applicant (s) _________________Address of Applicant (s) _______________________________________________________________________________________________________________________________________________________________________Date _________________                                  Signature of Applicant(s)/Authorised Official
(Space for comments of the Authorised Dealers)While forwarding the application to Reserve Bank ofIndia for approval, reference to ECM paragraph / ADcircular in terms of which the reference is made should invariably be cited.)Approval for similar remittances was obtained from the Reserve Bank of India vide permit No._________________ dated _________________.