A2 Form
A2 Form
A2 Form
FORM – A 2
Application cum Declaration Form
(To be completed by the applicant)
Application for drawal of foreign exchange
1. Details of applicant
a. Name : PRIMACY INDUSTRIES LIMITED
b. Address : PRESS CORNER
: MANIPAL – 576104
: KARNATAKA, INDIA
c. Account Number : 01111070000095
2. Details of foreign exchange required
Amount (Specify Currency) : USD 1,450.00
USD One Thousand Four Hundred Fifty only
a. Purpose : Audit Charges Invoice No.78680044531 dated
21.09.2017
b. authorize you to debit my Savings bank/Current/RFC/EEFC Account number 01111070000095 and
c. Issue a draft Beneficiary’s Name
1. Beneficiary’s Name :
2. Address :
d. Effect the foreign Exchange remittance directly
Beneficiary Name: UL Verification Service Inc.
Address: 62045 Collection |Centre Drive, Chicago, IL 60693‐0620, US.
Bank Name: BANK OF AMERICA, N.A
Bank address: 135 S. La Salle Street, Chicago, IL 60603, US.
SWIFT: BOFAUS3N
Account Number: 8666614487
ABA(ACH):071000039
ABA(Wire):026009593.
e. Issue travelers cheques for
f. Issue foreign currency notes for
Signature
DECLARATION
(Under FEMA 1999)
I, Prabhakar D Kamath, VP Finance & CFO, Primacy Industries Limited, Manipal declare that
1. The total amount of foreign exchange purchased from or remitted through all sources in India during this
calendar year including this application is within USD ________________ (US Dollars
____________________________________________________________________ only), the annual limit
prescribed by Reserve Bank of India for the said purpose.
2. Foreign exchange purchased from you is for the purpose indicated above.
Note: Gross amount credited to Beneficiary, all bank charges to Applicant
Date: 27.09.17 Signature
Name:Prabhakar D Kamath
FORM – A 2
Application cum Declaration Form
(To be completed by the applicant)
Application for drawal of foreign exchange
3. Details of applicant
a. Name : PRIMACY INDUSTRIES LIMITED
b. Address : PRESS CORNER
: MANIPAL – 576104
: KARNATAKA, INDIA
c. Account Number : 01111070000095
4. Details of foreign exchange required
Amount (Specify Currency) : USD 200.00
USD Two Hundred only
a. Purpose : Inline Inspection Charges Order No.11952278 dated
12.09.2017
b. authorize you to debit my Savings bank/Current/RFC/EEFC Account number01111070000095 and
c. Issue a draft Beneficiary’s Name
3. Beneficiary’s Name :
4. Address :
d. Effect the foreign Exchange remittance directly
Beneficiary Name: SEARS HOLDINGS MANAGEMENT CORP
Address: 3711 Kennett Pike, Greenville,DE 19807
Bank Name: BANK OF AMERICA, N.A
Bank address: 901 Main Street, 7th Floor, Dallas, TX 75202
SWIFT: BOFAUS3N
Account Number: 4427296338
Wire Routing: 026009593
e. Issue travelers cheques for
f. Issue foreign currency notes for
Signature
DECLARATION
(Under FEMA 1999)
I, Prabhakar D Kamath, VP Finance & CFO, Primacy Industries Limited, Manipal declare that
1. The total amount of foreign exchange purchased from or remitted through all sources in India during this
calendar year including this application is within USD ________________ (US Dollars
____________________________________________________________________ only), the annual limit
prescribed by Reserve Bank of India for the said purpose.
2. Foreign exchange purchased from you is for the purpose indicated above.
Note: Gross amount credited to Beneficiary, all bank charges to Applicant
Date: 27.09.17 Signature
Name:Prabhakar D Kamath