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To help us make sure your payment arrives at your institution on time and in full, please
complete your transfer as soon as possible using the instructions below.
These instructions are valid until 24/04/2018 12:31:45 EDT
*You cannot use this sheet after this date. If the date above has passed, go online again and create a new quote. Note that there will be a small
processing fee charged by ICICI Bank.

Due to Indian regulations, in order to complete your payment you will need to present the attached Outward Remittance
Request Form along with proof of identity and address at a local ICICI Bank branch.
To find the nearest ICICI Bank branch, please use their branch locator by clicking here.

1. Print the outward remittance request and payment instructions forms
2. Fill out the outward remittance request form. Note that much of the information has been pre-populated for your convenience.

Below are the items which are to be completed by the person making the INR payment (Remitter). It is important that all items
below are completed in full to ensure efficient processing of your payment.

Section I: The remitter fills in their name, address and phone number.
Section II.b: Fill in the designated amount of INR shown on the attached instructions in words. Ensure that the amount populated in numbers
as well.
Section III: ICICI account holders only - The remitter provides the ICICI INR account number to be debited for the payment. (Non-ICICI
account holders see item 4 below)
Section V: Provide the Student Name, Student ID and Country of Study Abroad.
Section VI: please ensure that the ICICI representative includes the displayed reference number with the wire payment.
Signature: The remitter signs and dates the Outward Remittance Request at the end of the declaration on page 3.

3. Take the printed/signed documents and present your proof of identify and address for verification by ICICI Bank*. The ICICI

representative will complete the KYC Certification with the remitter as applicable. Acceptable identification includes:

Proof of Identity Proof of Address

PAN Card Photo ration card Passport Certificate/ID Card/ Savings Pass Book issued by Post Office

Voter ID Card Senior citizen ID card Telephone Bill Latest premium receipt of any life insurance co

Driving License Passport Electricity Bill Consumer gas connection card/book/Pipe gas bill

Government ID Card Bank Statement with cheque Leave/Lease and License Agreement

4. Non-ICICI account holders will transfer funds locally from their respective bank accounts to ICICI Bank pool account through

NEFT/RTGS as per the details mentioned below:
• Beneficiary Name: Outward Remittance Pool Account
• Account Number: 0035SLORCBPC
• IFSC Code: ICIC0000035

5. ICICI Bank will process your request. Western Union Business Solutions will then deliver the payment to your school to

complete the payment.

Remember, we’re here to help. If you have any questions relating to this transfer, please contact
Western Union Business Solutions at studentinquiries@westernunion.com

© 2017 Western Union Holdings Inc. All rights reserved.

Western Union Business Solutions is a business unit of The Western Union Company. Services in the US are provided by Custom House USA, LLC (NMLS ID: 906985; MA MT license #:
FT906985) and Western Union Business Solutions (USA), LLC (NMLS ID: 907333; MA MT license #: FT0041) (collectively referred to as “WUBS” or “Western Union Business Solutions”). For a
complete listing of US state licensing, visit http://business.westernunion.com/about/notices/. For additional information about Custom House USA, LLC and Western Union Business Solutions USA,
LLC visit http://business.westernunion.com/About/Compliance-Legal.
For Official Use only
Track Number Originating Br. ID Scan Br. ID AD Code

(To be completed by the applicant in block letters using black ink pen)

Application for drawal of Foreign Exchange

I. Details of the Applicant (Remitter)
a. Name of the Applicant
b. Address (Not mandatory
for ICICI A/c holders)
Applicant Phone numbers

II. Details of Foreign Exchange required (Fill-up either II a or II b) (Ref Annex-II in page 6 for
applicable Currency Details)

II a. For remittance of fixed amount of Foreign Currency

Foreign Currency
Amount In
FC Amt in figures Words

(OR) II b. For remittance of equivalent of Foreign Currency of Fixed Rupee Amount

Foreign Currency USD INR
Amount In
INR Amt in figures 238,209.00 Words

II c. Purpose of Remittance with Purpose Code (For details refer Annexure – I in page 4)
Code Description
S1107 Education

III. I / We authorize you to debit my / our below Account together with your charges
* Charges * Charges
borne by borne by
beneficiary remitter X

* Charges will be to the Account of Beneficiary (BEN) if no option is selected

III a. Please issue

Telegraphic Transfer (TT) X (or) Demand Draft (DD)

Beneficiary Name


Beneficiary Address
1 2 A P P O L D S T S T R E E T
L O N D O N E C 2 A 2 A W

IV a. Beneficiary A/c Number (Incase of TT)


IV b. Name of the Bank where the beneficiary A/c is maintained (In case of TT)

IV c. SWIFT & SORT Code details of beneficiary Bank (In case of TT)
IBAN for remittance made to
UK, Europe, Bahrain Saudi
Arabia & UAE
Sort Code for remittance to
SWIFT code (or) routing Number for
UK (or) BSB Code for
remittance to any other Country
remittance to Australia

IV d. Beneficiary Bank address including Country at which the beneficiary maintains A/c ( mandatory
in case of TT in CAD Currency)

IV e. Furnish the following details of Correspondent Bank if the Foreign Currency is sent to a
Country other than the home Country of the Currency
SWIFT Code Correspondent Bank Name

V. If the purpose selected is one of the below then it is mandatory to furnish the details sought for
The relationship of beneficiary with the remitter (for list of close relatives refer the table given
➢ Maintenance
➢ Education The Student Name and Student ID (if any). Country of study abroad
➢ Purchase of
The location of property being purchased (Country / State)
Nature of instrument (Equity / MF / Debt Instrument) and country of incorporation of the
➢ Investment abroad
company in which the investment is made

List of close relatives as per Sec VI of Companies Act

Brother (including step Brother) Daughter’s Son’s Wife Mother (including Step Mother) Son’s Daughter
Brother’s wife Daughter’s Husband Mother’s Father Son’s Daughter’s Husband
Daughter (Including Step Daughter) Father Mother’s Mother Son’s Son
Daughter’s Daughter Father’s Father Sister (Including Step Sister) Son’s Son’s wife
Daughter’s Daughter’s Husband Father’s Mother Sister’s Husband Son’s wife
Daughter’s Son Member of HUF Son (Including step Son) Husband (or) Wife

VI. Furnish below if a message to be sent along with wire transfer on your behalf


I / We hereby declare that the total amount of foreign exchange purchased from or remitted through all sources in India during this
Calendar / Financial year including this application is within USD Limit as prescribed by RBI for the said purpose under FEMA 1999

I/ We hereby declare that the transaction mentioned above doesn’t involve, and is not designed for any purpose for which the drawing of
foreign exchange is prohibited under rule 3 of the FEMA Current A/c transactions Rules, 2000 read with schedule I therefore of Viz,
1. Travel to Nepal & or Bhutan
2. Transaction with a person resident in Nepal or Bhutan
3. Remittance out of lottery winnings
4. Remittance of Income from Racing / riding etc. or any other hobby.
5. Remittance for purchases of Lottery tickets, banned or prescribed magazines, football pools, sweep stakes, schemes involving money
circulations, securing prize money awards etc.
6. Payment of commission on exports made towards equity investments in joint ventures / wholly owned subsidiaries abroad of Indian
7. Remittance of dividend by any company to which the requirement of dividend balancing is applicable.
8. Payment of commission on export under rupee state credit route except commission up to 10% in invoice value of exports of Tea &
9. Payment related to “Call back services” or telephones.
10. Remittance of interest income on funds held in non-resident special rupee a/c schemes.
I / We, being a person(s) resident in India, hereby declare that for transactions done under the Liberalized Remittance Scheme (LRS) for
resident individuals, issued and amended by RBI from time to time, is not in the nature of remittance for margin calls to overseas exchanges
/ overseas counter parties under this scheme.
I / We, being a person(s) resident outside India, here by declare that under Sec 4(b) of FEMA Permissible Capital A/c Transaction
regulation, 2000, the transaction mentioned above doesn’t involve and is not designed for any repatriation outside India out of the proceeds
of any investment in India, in any form, in any Company, Partnership firm (or) Proprietary concern or any entity, whether incorporated or not,
which is engaged or proposes to engage
a. In the business of chit funds or
b. As Nidhi company or
c. In agricultural or plantation activity, or
d. In real estate business, or construction of farm houses (real estate business shall not include development of townships construction of
residential / commercial premises roads or bridges), or
e.In trading and transferable development rights (TDRs)
I / We being a person(s) resident outside India, here by declare that no portion / part of outward remittance represents interest on refunds of
funds received from outside India for purchase of shares in India. Updated list of prohibited transactions under FEMA can be accessed on
ICICI Bank website (www.icicibank.com).

Other relevant declarations:

I/we hereby declare that the purpose and transaction details as mentioned above are true to the best of my knowledge does not involve,
and is not designed for the purpose of any contravention or evasion of the provisions of the FEMA, 1999 or any rule, regulation, notification,
direction or order made there under. I/We agree that I/We shall be responsible and liable for any incorrect detail provided by me/us.
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 agree that in the event of transaction could not be executed/debited to my/ our account after submitting the request for processing to
the bank on account of insufficient/ unclear balance at the same time of execution of the transaction in my/ our account any exchange
losses incurred in this connection due to reversal of the Forex deal can be charged to my/our ICICI account.
I/we agree that in the event the transaction is cancelled or revoked by me/us after submitting the request for processing to the bank any
exchange losses incurred in this connection can be charged to my/our ICICI account. I/we further agree that once the funds remitted by
me/us have been transmitted by ICICI bank to the correspondent and/or beneficiary banks, ICICI bank shall not be responsible for any
delays I the disbursement of such funds including the withholding of such funds by the correspondent and/or beneficiary banks. I/We further
agree that once the funds remitted by me / us have been transmitted by ICICI Bank, intermediary Bank charges may be levied by
Correspondent and / or Beneficiary Banks, which may vary from bank to bank.
I/we agree that in the event the transaction being rejected by the beneficiary bank because of incorrect information submitted by me, any
charges levied by the beneficiary bank or exchange losses incurred in this connection can be charged to my ICICI bank account.
I/we also understand that if I/we refuse to comply with any such requirement or make only unsatisfactory compliance therewith, the bank
shall refuse in writing to undertake the transaction and shall, if it has reason to believe that any contravention/evasion in contemplated by
me/us, report that matter to the RBI.
I/we also agree that the exchange rate will be applicable at the time of deal booking and may vary from the rate prevailing when the request
is submitted . I/we also understand that the rate communicated to us (if any) is an indicative rate and the actual rate may be different from
the same.
I / We authorize you to remit outwardly as per details provided in the application.

Date ……………………. Signature of Remitter / Mandate
(The signature by mandate holder will be accepted only for Non resident A/c holders where mandate is duly registered with the Bank )

I certify that I have verified the Customer’s signature as per Bank records and retained the originals of all the scanned
documents and forms submitted by the remitter for the above transaction.

Name & employee ID Bank Stamp & Employee Signature


(For Office Use Only)

KYC Certification
(To be filled and scanned only in case of remittance by non ICICI Customer)
I met Mr./Ms./Mrs. _______________________________ at his / her residence / office / other location (specify)

________________________________ and hereby confirm the identity and address given below

1. Remitter Name

2. Remitter Address

I confirm having verified the copies of documents (as applicable) with the originals produced by the applicant.
Also I confirm that the applicant has signed the documents in my presence. List of KYC documents provided.

ID Proof

Address Proof

Name of the Bank official ___________________________ Employee No. ____________ Designation


Date : _______________ Signature of the Branch Official and Branch stamp

Name of BM / BOM authorizing KYC certification above ______________________ Employee No.


Date : ______________ Signature of the Branch Official and Branch stamp

Details of INR amount credited to the pool a/c (Incl. of Charges + Service Tax) _______________________

Finacle Tran ID. _________________ IBR No. _____________________ Date of credit

______________________ into Pool A/c No.0035SLORCBPC (incase of any other a/c specify)


(If the remittance is by way of accepting cash deposit then the amount should not exceed INR 50,000/-)