AXIS BANK TRAVEL CURRENCY CARD – Refund Form

TRANSACTION DETAILS

Currency Option USD  EUR  GBP  AUD  CAD  SGD  CHF  SEK  JPY  AED  SAR 
NZD  ZAR  THB  DKK  HKD 
Refund Amount: In figures____________ In words____________ ________

Type of Encashment : Partial / Full

Have you settled your Forex with you company : Yes / No If No, Amount due to them :

Card Number    

Pan Number 
PLEASE TELL US ABOUT YOUR SELF

Name of the Employee Mr. /Ms/ Dr________________________ _____________________

Corporate Employee Code/Number :

Date of Birth ______________ Gender: Male / Female

Mother’s Maiden Name ________________ __________________________________________

Postal Address as per passport ________________________________________ _____________

_________________________ City __________________________ Pin_____________________

Phone no _________________Mobile __________________ Email____ _____

PLEASE FILL IN THE FOLLOWING INFORMATION

Passport Number ______________________ Place of Issue ________________ ________

Date of Issue ______________________ Expiry Date __________________ ______

Mode of Encashment

How you want your refund : NEFT

Bank Name and address :

BANK A/c Number :

IFSC Code :

Pay Order Favoring : NEFT

(Cheque/ Pay order / DD will be issued only in favour of card holder )

I hereby apply for the issue of a AXIS BANK Travel Currency Card to me and declare that the information included in the application form is true and correct and
that I am a resident Indian and that I am eligible to apply for an internationally valid card. I accept that AXIS BANK is entitled in its absolute discretion to
accept or reject this application without assigning reasons whatever. It is my responsibility to obtain the terms and conditions applying to the AXIS BANK Travel
Currency Card Separately and read the same. If this application is accepted. I will be bound by the terms and conditions governing the AXIS BANK Travel
Currency Card, as may be in force from time to time and use of this card shall be deemed to be acceptance of these terms and conditions. I authorize AXIS
BANK and or its associates to verify any information or otherwise at my office/residence or to contact me, my Employer/ Banker / Credit Bureau/ RBI or any
other source to obtain or provide any information that may be required for confirming membership requirements or maintaining my account in good standing. I
agree to an ongoing confirmation for use of my name/address, email/ mobile nos. for marketing / merchandising offers between AXIS BANK and other
companies. I understand and acknowledge that the local laws and RBI rules and regulations lay down norms and limits for purchase and use of foreign
exchange. I undertake that the usage of AXIS BANK Travel currency card by me will be in accordance with the exchange control regulations of RBI and
applicable laws in force from time to time. In particular and without limitation, the FEMA act 1999, in event of failure on my part to do so or in the event of any
information supplied by me being incorrect or inaccurate. I agree that I will be solely liable for any penalties and / or action under the local laws and/or
regulations as may be in force, governing the purchase and use of AXIS BANK Travel Currency Card.

Signature of Primary Card Member__________________________________ Date_____________

Note: Please provide correct A/c no and IFSC code. As the credit will be effected solely on the A/c no and IFSC code
information.