CITY UNION BANK LIMITED Branch___________

Application for Remittances for Import of Goods

Name & Full Address of the Applicant -

Account Type SB/CD/CC/EEFC Account Number

Request for Currency Amount

Wire Transfer
Country of Origin
Shipment From
of Goods
Name & Full Address of the Beneficiary -

For Wire Transfer

Account Number of the Beneficiary

Name of the Beneficiarys Bank Beneficiary Bank

Swift Code
IBAN Number Sort Code BSB Code
(For UK, Europe, UAE, Bahrain, Saudi Arabia) (For UK) (For Australia)

Type of Payment

Collection Bill. Please specify Bank Reference Number ____________

Advance Remittance

Direct Remittance

Documents Submitted Overseas Bank Charges

Proforma Invoice/Invoice To be collected from me/us (OURS)
Sales Contract To be deducted from the beneficiary (BEN)
Bill of Entry (in case Direct Remittance) To be shared between me/us & the beneficiary (SHA)
Form 15 CA/CB

I/We hereby authorize you to debit my/our above mentioned account number equivalent Indian Rupees and effect the remittance as
per the mode indicated above. The bank charges may please be debited to the above said account. I/We hereby certify that I/We have
sufficient balance in the account. I/We hereby confirm that the import of goods made/to be made are as per Foreign Trade Policy in
force from time and does not relate to any banned entity/country not limited to US/UN/OFAC/EU/Other Regulations. If the funds are
blocked due to any such ban/restrictions I/We shall not hold City Union Bank responsible for any loss that may be caused to me/us.
I/We hereby confirm that the details of the beneficiary provided above have been verified by us and the bank will be in order in
effecting the payment as detailed above. I/We hereby undertake to submit the Exchange Control Copy of Bill of Entry (evidence
towards import of goods into India) within the specified time as stipulated in the FEMA guidelines from time to time. I/We understand
that the bank will be at liberty to reject the above request if not satisfied about the bonafides of the transaction or the bank will be at
liberty to process the request only after ascertaining the bonafides of the transaction in any manner as it may deem fit.

Signature of the Importer

Declaration under Section 10(5), Chapter III of the Foreign Exchange Management Act, 1999
I/We hereby declare that the transaction, the details of which are specifically mentioned in the schedule hereunder, does not involve,
and is not designed for the purpose of any contravention or evasion of the provisions of the Foreign Exchange Management Act, 1999,
or any rule, regulation, notification, direction, or order made there under. I/We further agree to give you all such information/particulars
as may be required by you and called for by you to determine whether such transaction contravenes any of the Foreign Exchange
Management Act or any other rule, regulation, notification or order made there under. I/We hereby declare that all the
information/particulars given by us are true and correct to the best of my/our knowledge and information. I/We also understand and
agree that if I/We refuse to comply with any such requirement or make only unsatisfactory compliance therewith, the bank is always at
liberty to refuse in writing to undertake the transaction and shall if it has reason to believe that any contravention/evasion is
contemplated by me/us report the matter to Reserve Bank of India. * I/We hereby declare that the undersigned has/have the authority
to give this declaration and undertaking on behalf of the firm/company.

Date: Signature of the Importer