Name of the Company

Sr.

Name and Address

Nationality

Origin

Value

Amount

Mode of

Bank

No.

of investors

of CP

received

Receipt

Certi-

(State

(By direct

ficate

issued

currency)

remittance

Number

(Rs.)

or by

and date

debit

NRE/FCNR/

NRO

account)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

We hereby certify that the particulars given above are true and correct to the best of our

knowledge and belief and in accordance with the terms and conditions stipulated in Reserve

Bank (IECD) approval No.

dated

.

Date:

(Signature of Authorised Official)

Name:

Stamp

Designation

Name & Address

of the company

NOTE:

To be countersigned by the banker (authorised dealer) to whom approval letter has

been issued by RBI (IECD)