This document is a request from an individual to HDFC Bank Ltd. to issue foreign exchange for the purpose of remittance, with details provided about the remitter, beneficiary, amount, currency, and mode of payment. The remitter declares that the transaction does not involve any contravention of FEMA regulations and agrees to provide information to reasonably satisfy the bank. Upon approval, the bank will process the remittance by debiting the specified account or cash and issue a draft, telegraphic transfer, or traveler's cheque.

1. The Manager, Date:_______________
HDFC Bank Ltd.________________________________Branch
Dear Sir,
This is a request to issue me Foreign Exchange as requested below :
Purpose of remittance: _________________
____________________________________
____________________________________
Mode (Please provide exact split of amount, if any)
TT__________ Draft__________
TC__________ Cash__________
In case of TT – Correspondent Bank Charges
to be borne by:
Self* The Beneficiary**
Details of the Remitter:
Name ________________________________________________________ Nationality __________________________________________________
Address#
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Tel. / Mobile.________________________________________________________________________________________________________________
Passport Details (Refer table overleaf):
Passport Number________________________________________________ Date and place of issue__________________________________________
PAYMENT MODE
For Account holder
I authorize to debit my HDFC BANK SB / CAAccount No. Signature_______________________________
OR
HDFC Bank Cheque No##._________________________________________________
For Non-Account holder
Cash up to Rs. 50,000/-only Other Bank Cheque / DD / Pay Order______________________ Bank Name_______________________________
___________________________________________________________________________________________________________________________
FCY Currency Type FCY Amount _________________FCY Amount in words___________________________________________________
Beneficiary details (mandatory for TT Transfer)
Name___________________________________________________________ Account No.________________________________________________
Addres_____________________________________________________________________________________________________________________
Name and Address of the beneficiary’s banker______________________________________________________________________________________
SWIFT Code_____________________________________________ ^BSB/ABA Routing No. IBAN No. / SORT code___________________________
1^ For all GBP remittances - 6 Digits SORT code of Beneficiary Bank in UK is required. 2) For all EUR remittances – IBAN No. of Beneficiary is mandatory
3) For allAUD remittances - 6 digit BSB No. of Beneficiary Bank is required. 4) For all CAD remittances –Bank code and Transit No. for Beneficiary Bank is required. 5) Proper purpose
codes must be provided as per RBI guidelines.
I / We hereby declare that the transaction, the details of which are specifically mentioned in the application above, does not involve and is not designed for the purpose of any contravention
of evasion of the provision u/s 10 (5) chapter III Fema 1999 or any rule, regulation, notification, direction or order made thereunder. I /We also hereby agree and undertake to give such
information / documents as will reasonably satisfy you about this transaction in terms of the above declaration.
I/ We also understand that if I / We refuse to comply with any such requirement or make only unsatisfactory compliance there with, the bank shall refuse in writing to undertake the transac-
tion 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 further declare that the undersigned
has / have the authority to give this declaration and undertaking on behalf of the firm / company.
I hereby declare that the above details are true and that this remittance along with my previous remittance does not exceed the limitation, under the category, allowed as per RBI regulation.
Signature of the Remitter:_________________________________________________________
For documentation refer table given overleaf.
FOR OFFICE USE ONLY
Processed by Authorized by Ref. NO.
DD/TT/TC No. FCYAmt. INR Amt.
Conv Rate TC Cr A/c No. Dr. A/c No. cash
DD / TT
Cash
Charges ( Rs ) Cr. a/c no.
Charges waived (Rs.) Cr. a/c no. Dr. A/c No
Confirmed that de-duping is done for remitter and beneficiary from Banned list.
Empl code___________________ Empl Name___________________________________________________________ Sign_______________________________
Customers copy: (to be Produced by the customer while collecting DD / TCs / TT confirmation from Bank)
DD / TT / TCs for (Amount) __________________________________________________
Remitter’s Name___________________________________________________ Beneficiary___________________________________
Customer Account No. /Cash_______________________________________________________Date___________________________
Customer Type - Bank Account Holder Non Bank Account Holder
Status - Residents NRI
BANK
SEAL
*Will be collected after the remittance is affected. ** Beneficiary will receive the amount after deduction of Correspondent Bank Charges.
#
For customer not having an account with HDFC Bank
##
Applicable for remittances only