A.D. Code No._ ______________F o r m N o .

_ _ _ _ _ _ _ _ _ _ _
(To be filled by authorised dealer)

S e r i a l N o . _ _ _ _ _ _
Form A1 (For Import Payments only)
for use of Reserve Bank of India)
Application for Remittance in Foreign
Amount _________________
Currency
remitted Currency Amount
Equivalent to Rupees___________________
(To be completed by authoriseddealer)

I/We wish to purchase (Name of Currency) EURO 36,359.62(Amount in words EURO Thirty Six Thousand
Three Hundred Fifty Nine and 62/100 Only) through (Name and address of the authorised dealer) Vijaya
Bank, Manipal Branch Manipal – 576104 for payment to (Name and address of the beneficiary of the
remittance) Henschkedocht., in payment of imports into India, detailed below:

Details of goods imported or to be imported into India

Section A: Import License particulars

Face value Amount to

Import Licence Date of Issue Date of expiry be
of licence
Prefix Licence No. Suffixes Date Month Year Date Month Year endorsed
(in Rs.)
1 2 1 2 3 4 5 @

@ Actual amount endorsed in rupees against each licence involved should be stated under this
column.
Note: If more than one licence is involved, particulars of all licences should be furnished. If the space is
inadequate, separate statement may be attached. The amount utilised against each licence should
invariably be indicated.
Section B: Import particulars

approximate date)
Invoice Details
Date of shipment
river, transport
origin of goods

shipment (air,
Description of

are consigned

sea post, rail

Country from
Classification

(if not known

which goods
Harmonised
Quantity of

Country of

port, etc.)
System of

Mode of
f.o.b., c.&.f.
No & Date

goods
goods
Currency

Amount
Terms
(c.i.f.,

etc )

36,359.62
EX Works

Germany

Germany
EURO
EURO
429702188

28.08.2017

Wick

Sea
dated

Section C: Other particulars

1. Details of forward purchase

(No.& date of (Currency and Amount (Balance under the
contract, if any, booked against the
Contract of Contract) contract)
import

24. If remittance to be made is less than invoice value, reasons

there for (i.e. part remittance installment etc.)

I/We hereby declare that the statements made by me/us on this form are true and that I/we have
not applied for an authorisation through any other bank.
I/We declare and also understand that the foreign exchange to be acquired by me/us pursuant
to this application shall be used by me/us only for the purpose for which it is acquired and that the
conditions subject to which the exchange is granted will be complied with.

(Signature of Applicant/Authorised Official)

@ Name and Address of Applicant. PRIMACY INDUSTRIES LIMITED
Date:14.10.2017 Seal Importer's Code Number: 0704014378
@ Nationality: INDIAN
@ To be filled in capital letters
 Declaration to be furnished by Applicant
I/We declare that
(yyy) the import licence/s against which the remittance is sought is/are valid and has/have not been
cancelled by DGFT.
(zzz) the goods to which this application relates have been*/will be* imported into India on my/our own
account*
(aaaa)the import is on behalf of @ _______________________________________________________ * and
(bbbb) the invoice value of the goods which is declared on this form is the real value of the goods
imported*/to be imported* into in India.
If the import has I/We attach the relative Customs-stamped Exchange Control copy of Bill of Entry
been made *Post parcel wrapper (for imports by post)*/Courier (for imports through courier)*
If the import is to be I/We undertake to produce within three months to the authorised dealer the
made relative Customs-stamped Exchange Control copy of Bill of Entry * Post parcel
wrapper (for imports by post)*/Courier wrapper (for imports through Courier)*

* Strike out item not applicable

@ Where the import is on behalf of Central/State Government Department or a company owned by

Central/ State Government/Statutory Corporation, Local Body, etc. the name of the Government
Department, Corporation etc. should be stated.

Date:14.10.2017
(Signature of Applicant/Authorised Official)

Space for comments of the authorised dealer

(While forwarding the application to Reserve Bank for approval, reference to Exchange Control Manual
paragraph/ A.D.Circular in terms of which the reference is made should invariably be cited. If any
remittance application on account of the same import was referred to Reserve Bank earlier, reference
to the last correspondence/approval should also be cited).

(Signature of Authorised Official)

Name ___________________________________________________

Date: Seal Designation_______________________________________________

Name & address __________________________________________

Authorised Dealer______________________________________

Certificate to be furnished by Authorised Dealer (Importer's Banker)

We hereby certify that

(w) this payment is

i. an advance remittance
Put a tick in the relevant Box

ii. in retirement of bills under Letter of Credit opened through us

iii. against documents received through our medium for collection
√ iv. on account of documents received direct by the applicant/s against undertaking
furnished by the latter to submit Customs-stamped Exchange Control copy of Bill of
Entry of Post Parcel/courier wrapper within three months
v. on account of documents received direct by the applicant/s against undertaking
furnished by the latter to submit Customs-stamped Exchange Control copy of Bill of
Entry of Post Parcel/courier wrapper within three months
vi. any other case to be explained _____________________________________________

(tt) all the Exchange Control regulations applicable to the remittance have been complied with

(uu) the payment to the supplier of the goods has been* /will be made through (Name & Address of
the foreign bank)

We also certify/undertake that the relevant Customs-stamped Exchange Control copy of Bill of Entry or
post parcel/courier wrapper

 shall be verified by us within three months[vide certificate (a)(ii) and (iii) above].
 has been verified [vide certificate (a) (v) above].