For Bank use only

Card Pack ID
First Card
No.
Second Card
The Manager No.
Bank of Ceylon BOC MULTI CURRENCY PREPAID TRAVEL CARD
APPLICATION
……………………………….
Please issue a BOC Multi Currency Prepaid Travel Card as per details provided below:
Fields marked with * are mandatory

PERSONAL INFORMATION

*Title : Mr. Mrs. Miss Dr. Other…………

*Full Name :

Name with Initials :

* Marital Status : Married Single * Gender : Male Female

* Nationality : * Date of Birth : D D M M Y Y Y Y

* Mother’s maiden name:

Are you a US person under the Foreign Account Tax Compliance Act (FATCA) of US? Yes No
If Yes, FATCA declaration and W9 Form have to be submitted along with this application form.
CONTACT DETAILS

Residence Number : Office Number :

Mobile Number : Mobile No. to be :
used during travel
E-mail :

Alert Option : E-Mail SMS Statement Preference : E-mail Print

*Preferred Mailing Address: Current Permanent Office

Permanent Address :

Current Address :

Office Address :

OCCUPATIONAL DETAILS

*Employment status : Self Employed Contractual Permanent Retired Business other…………………

Employer Type : Non Government Government Public Private
*Employer Name : Department :
Designation : * Net Annual Income :
*Income Source : Salaried Business Income Other ……………………………..

DETAILS OF TRAVEL DOCUMENTS / NIC

*Passport Number : *Place of Issuance:

*Date of Issue : D D M M Y Y Y Y *Date of Expiry D D M M Y Y Y Y

*NIC Number : * Ticket No. :

TRAVEL DETAILS

*Country of Travel : * Number of Days of Travel :

*Date of Travel : D D M M Y Y Y Y * Arrival Date: D D M M Y Y Y Y

* Type of Travel : Business Leisure Medical Official Other …….……………

 TRAVEL CARD DETAILS
Card Loading:
Currency Priority* Load Amount Payment Currency: ………………………………………………

Payment Mode: Cash

A/C Transfer
(BOC A/Cs only) A/C No. ……………………
*Please mark 1,2,3 as per your preferred currency order. The above ranks of currencies will be followed in case of insufficient balances. Charges will
be applicable for cross currency transactions.
I (full name) …………………………………………………………………………………………………………………………………………………………hereby declare that, I
am eligible to apply for International Travel Card and the information furnished in the application is true and correct. I read,
understood the terms and conditions of BOC Multi Currency Prepaid Travel Card and the use of the Travel card shall be deemed to
be an acceptable of those terms and conditions.
I also agree to comply with the Directions under Foreign Exchange Act No.12 of 2017 and regulations imposed by Bank and Central
Bank of Sri Lanka (CBSL)issued from time to time. I shall keep evidence in respect of withdrawals/transactions done using the Travel
Card and use for personal nature current transactions for payments outside Sri Lanka, other than for payment for import of goods to
Sri Lanka for commercial purpose. I shall seek prior written permission from the Director-Department of Foreign Exchange for any
payments outside Sri Lanka for purposes falls outside the purview of Directions published by Department of Foreign Exchange of the
Central Bank of Sri Lanka. I undertake to inform the Bank of my return to Sri Lanka and return the unutilized value remaining in the
above travel card, prior to lapse of 90 days from the date return to Sri Lanka, in complying with CBSL regulations. Further, in the
event, if I become a US person under the Foreign Account Tax Compliance Act(FATCA) OF US, I do hereby undertake to inform the
said fact to the bank immediately.

Date : ……………………………………… Signature of the Applicant: ……………………………………………………………………

DECLARATION

(A) DECLARATION BY THE APPLICANT FOR A FOREIGN TRAVEL CARD (FTC)

To: Bank of Ceylon,

I ………………………………………………………………..(Name of the FTC applicant) bearing Passport number………………………… hereby authorize
Bank of Ceylon to credit the unutilized foreign currency remaining in the FTC to my foreign currency account …………………………….(A/C
No.)/ convert into Sri Lanka rupees and credit to my LKR account …………………………… (A/C No.) upon 90 days of my return (delete
which is inapplicable).
I………………………………………………………………..(Name of the FTC applicant) declare that the above information is true and correct.

Date: ……………………………………… Signature of the FTC Applicant: ……………………………………………..

(B) DECLARATION BY THE APPLICANT FOR ELECTRONIC FUND TRANSFER CARDS (EFTC)

To: Director - Department of Foreign Exchange

I ………………………………………………………….… (Cardholder) declare that all details given above by me on this form are true and correct. I
hereby confirm that I am aware of the conditions imposed under the provision of the Foreign Exchange Act, No. 12 of 2017 (the Act)
on Electronic Fund Transfer Cards (EFTCs) subject to which the card may be used for transactions in foreign exchange and I hereby
undertake to abide by the said conditions. I further agree to provide any information on transactions carried out by me in foreign
exchange on the card issued to me as Bank of Ceylon may require for the purpose of the Act.

I am aware that the Authorized Dealer (bank) is required to suspend availability of foreign exchange on EFTC if reasonable grounds
exist to suspect that unauthorized foreign exchange transactions are being carried out on the EFTC issued to me and to report the
matter to the Director- Department of Foreign Exchange. I also affirm that I undertake to surrender the Card to Bank of Ceylon, if I
migrate or leave Sri Lanka for employment abroad, as applicable.

Date : ……………………………………… Signature of the Cardholder: ……………………………………………..

I, as the Authorized Officer have carefully examined the information together with relevant documents given by the applicant and
satisfied with the bona-fide of these information and documents. I undertake to exercise due diligence on the transactions carried
out by the cardholder on his/her EFTC in foreign exchange and to suspend the availability of foreign exchange on the EFTC if
reasonable grounds exist to suspect that unauthorized foreign exchange transactions are being carried out on the EFTC in violation
of the undertaking and to bring the matter to the notice of the Director-Department of Foreign Exchange.

Date : ……………………………………… Signature of the Authorized Officer: ……………………………………………..

ACKNOWLEDGEMENT

I ……………………………………………………………………………………………………. hereby confirm the receipt of BOC Multi Currency Travel Card
(Primary and Secondary cards) and PIN Mailers.
Date - …………………………………… Signature of the Card Holder - ………………………………………………

For Bank use only –

Documents check list:
Loading to travel card: Completed Application Form No. 1
Load Load Exchange rate Deposit Deposit
Currency Amount applicable currency Amount Copy of Passport Copy of VISA
Copy of Air Ticket

Commission Income received: ……………………………………………

System Entries Passed: Core-Banking System : Yes/No

Total
MasterCard System : Yes/No

Date : ………………………… Signature of the Officer: ……………………………….…….. Branch: ………………………………