Application cum Declaration Form for release of Foreign Exchange under Business Travel

(To be obtained on company's letterhead)

Date: 18.01.2022
To,
The Manager
Ebixcash World Money Ltd.
Nagpur

We request you to release foreign exchange to our personnel for his/her visit abroad as mentioned below.
A. Name of Person: Aarti Verma
B. Designation: BI Consultant
C. Residential Address: Plot No. 241- 242, Mangalam Apt., Near Lendra Park, Ramdaspeth, Nagpur
E. PAN No. AQEPV2639L
F. Passport Details:
Passport No. Place of Issue Date of Issue Expiry Date
K6784202 Nagpur 12/10/12 11/10/2022
• Foreign Exchange Requirement:

Country/Countries to be Purpose of Visit Duration of stay abroad Total Foreign Exchange

visited (No. of days) required
Spain BUSINESS 5 days CNs : 200
TCs :
PPCs 1700

G. Air ticket no.: Airlines Qatar Date of Travel: 9th Jan’22

Declaration:
It is certified that the expenses for the above trip are being borne by firm/company and we undertake that the same shall be
utilized for the purpose stated above. It is hereby declared that the transaction, the details of which are mentioned above does not
involve, and is not designed for the purpose of or in contravention or evasion of any provision of the Foreign Exchange
Management Act, 1999 or of any Rule, Regulation, Notification, Direction or Order issued / made thereunder. We also hereby
agree and undertake to submit information/documents as will reasonably satisfy you about this transaction in terms of the above
declaration. I/We further confirm that the foreign exchange released for the above mentioned purpose shall be used within 180
days of purchase. In case it is not possible to use the said foreign exchange within the period of 180 days, same shall be
surrendered to an Authorized Person. We further declare that the undersigned has the authority to give this declaration on behalf
of the firm/company. We also understand that if the complete details as required above in A to H and the required KYC
documents are not furnished, CentrumDirect Limited shall refuse in writing to undertake the transaction and shall, if it has reason
to believe, may report the matter to Reserve Bank of India(RBI) / Financial Intelligence Unit(FIU). This application for release of
foreign exchange as above is being made in accordance with the provision of RBI Master Circular on Miscellaneous Remittances
from India – Facilities for Residents. We undertake that the foreign exchange released vide this application shall be utilized for the
employees overseas travel only.
We enclose our Cheque / DD No. 004394 dated 13-01-2022 for Rs. 2, 88,020.00 Drawn on Ebixcash
World Money Limited towards cost of the foreign exchange.

Thanking You,
Yours sincerely,
For M/s _______________________
Signature
Name & Designation