Form A2

Application cum Declaration
(To be completed by the applicant)
Application for drawal of foreign exchange
I. Details of the applicant -
a. Name :
b. Address:
c. Account No :
Bank Address:
Branch Name:
II. Details of the foreign exchange required
1. Amount : (Specify currency)
2. Purpose : Code S0305 Overseas Education Tuition Fee/Hostel Fees
III. Authorize you to debit my Saving Bank/Current/RFC/EEFC Account No. **Not Applicable**
together with your charges and
* a) Issue a draft: Beneficiary's Name: Not Applicable
Address: Not Applicable
* b) Effect the foreign exchange remittance directly –
1. Beneficiary's Name :
2. Beneficiary Address:
3. Account Number:
4. Bank Name:
5. Bank Branch Address:
6. Swift Code/Routing Code/IBAN:
* c) Issue travelers cheques for: Not Applicable
* d) Issue foreign currency notes for: Not Applicable
(Strike out whichever is not applicable)
Signature ________________________________
Declaration
(Under FEMA 1999)
I, declare that –
* 1) The total amount of foreign exchange purchased from or remitted through, all sources in India
during this calendar year including this application is within ___________________________________
(USD ) the annual limit prescribed by
Reserve Bank of India for the said purpose.
* 2) Foreign exchange purchased from you is for the purpose indicated above.
(Strike out whichever is not applicable)
Signature __________________________
Name: ___________________________
Date:
peerTransfer Education Corporation
200 Portland Street, Suite 301 Boston, MA 02114
-
Citibank NA
200 Technology Sq, Cambridge, MA 02139
CITIUS33/221172610/NA
SIDDHARTH SINGH
531, KANPUR, UTTAR PRADESH, 208024, India
16,831.21 USD

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