Annexure - A

Simplified Application cum Declaration in lieu of Form A1(For lmport payments of Value not exceeding USD 5000)

AD Gode:

l. Details of the applicant:1. Name:2. Address:3. PAN No.4. Line of Business

ll. lmport Particulars:

L-rCountry ofOrigin ofGoods

transport portetc)

O"t. "fshipment(if

known) ortentativedate(approxdela\

lll. Details of the foreign exchange to remit; -1. Amount (Specify currency):2. Purpose: (Advance Remittance/ Against

' Shipping Documents)

lV. I authorize you to debit my/our/GurrenUEEFG/CC Account No. togetherwith your charges and effect the foreign exchange remittance direcfly to'1

. Beneficiary's Name:2. Address of the Beneficiarv:3. Name and address of the Bank / BIC Code:4. Account No.:

Declaration

1. lANe hereby declare that the statements made by me/us on this form are true and that l/we havenot applied for the same remittance through any other bank.

2. lWe declare and also understand that the foreign exchange to be acquired by me/us pursuant tothis application shall be used by me/us only for the purpose for which it is acquired and that theconditions subject to which the exchange is granted will be complied with. All ruies and regulationsissued under FEMA governing imports has been / will be adhered bv me /us.

Date:Place

(Signature & Stamp of Applicant/Authorized Official)