R8;nih5h tca
Pb86 rtu h urrn! BLoC( L.hdr
n€ar€ (/, litE€ .prlt bl.
'lndk.l8! dddaro,y l dha onrdh606rd.d
o Applicant' (Remitter) lnfornation
Nem€ or Apprcant, {.'l-rr*Jrl..t1*shil9r.y.Sllffi l4ior. *",","n"" ruo
Dale'
- P 6se lr4 it lhi3 is 3ahe 63 oeb\ ac.ounr
o Remittance Amount
Pleaee 6rd C!fti.y or Rc6{iik
curancyornemtttance' .U$..0........
9 'r i\i s t ne*v
F:tvfl Th l) nd 0 Llvnd ^a.[ Six 6
a Amount to be Rsmiited'
o lntermedlary Bank lnlormetlon (Optional)
Banl Name'
E _ SHA-Local charge! bom6 by renllter & oveBe.s by benp,iciary
\Ef OUF-alllocaland overs€ae chargsE borne byrsmrn€r
- 8EN.AX locd and ov6rs6as cna0as bom6 by b.n.fici.ry
o Reclplent's (Benefi clary) lnformrtlon
Account No. / |SAN ' 2Loobl? ?€4
swrFr/crea,ins code' .9-Q.I:.Kr..Hg.X,.........
1.222.P6)ha'.3.(06Jr.Bnr'6!r-K.'
Recipaent s Bank Delails
il";;- E.r:he,F&.,Jhy6 fl,-hlrtft,.iB
counrry' fto+lnrr'4 l
l{
SWFT / Clearins Code: ..
tr! ntr ti Pr€..e tick.ma ln spp,opnar6 .hick borlol) ns
{
Country '
o Paym€nl Dstalls (e.9. lnvolce, Rersrence, etc......)
. [ryp,.<-s....ni0.' ..?.99.2 21i .. . .
o Purcoso ol Rsmittance
f)nk"iocJ,a,,d y'-4a naoonc^l i a-e
;;;:,"";;.;;;;;,,J9;;"".;";.;;,"";",,".,;;..;;*,"","6d,,1@.'.sos ch,na(,o,cNy, hd. J..d.n Ms.vr,, partrsr61d
Appllcanfs Slgnrtt rs
o 6d dl .pp[6n''s knowicde ! co hplar., Apdr @lion ro bo submd.d ih id 3d d;M oJ }\ olncMB ac. i nr
Apprkld .hrrr bes .ny d .ll r.si.. 6&nins rrcm durkit En [.ice aPPlrqrdi
^Dpkrd iherd rub'nir.dmlfir.csn lEatoi .or 6ad .sp,Eto rcn[*s.. lNr ro,m '. nor hreldod rd lit
* Ehidrno rprndhn ror Ecumng r.drn nc.r.
Appll6,n !!6ei lo b. b&nd by rha iomtrlancs S.(lca l6mt &@oatrv.9 r. rom dM/or svuihu. alrfo
ron.p!!lenoyoub.tl.r,ft'.@mm.idut.ae.looe'.cto^lccha^hekIh.nrv.u.irbanhnqmrr'FBI-
o For lntarnal use Only
lj 2- 6 5
id ea
D
t rr" N]
Prime Bank
L@LZtal
Cha,ges Dobit A./C No ' U rEti?66EEZ
I i.ttj
l_l
Remittance Service Terms
These Terms aupptement th€ orlstlng lerms and c.ndilions govemlng Applicarl s eccounl used lor lhe Remitlance SeMce. To the erlenl ol6ny
incooslste,rcy, lhese lerms shsll ptovall.
Remtitrnce Servlce: (s) SAnk shgll !!e rc6sonable €ro and lklll ln providing lhe Rsmlttence SeNice. (bl unless e leter dete ls specified in lh8
aprtication, gank sh€ll seek lo eiecute lhs .emitlanc6 on lhe busi.ssi day lhal Sank racelves lhe rEmitlsnco applicallon, i, rccaived pdor lo lhe
spplic€ble culnil time at Eonk'3 lelrlca loc6lion: olheftviso, Bank shall seek to ercculo lhs rot ltonae on the nerl tusiness day. The romitlance may
tako tonger lhan one bdslnesa day to ereoJte. (c) Sank msy instruct it afliliate, a^olhor bank. . cl€ldng hou36, a psyrnenl, deating or 3elllement
syslem or olier p6ymonl lntomedlray (each o 'DaFnenl inlamediad) l. lhe oreculion o, tha r€mitlan.€. Each pEymanl lnlEmediary may tely on
Applicant's rcmnbnce lnstrucllons as If dkedsd lo ll, (d) g6nk may nol 6x6qJl€ lh6 r6mifrsnce i, Applicsnt 6 account has insuficiEnl ,unds. (e) Upon
Applicants wrltten requosl, Sank shall uss raosonablg ofloni io canoel or dop lhe rcmitiance: holvsv€., Benl shall not bo responslblo il lrrs
remittance ls execut8d, (0 86nk mey act oo lncomplel6 or lnconsistonl lnsllrcton! if Eank laasofiEuy b3li6v6s lhal it can complele or darify suc}l
informrllon vdlhoul rer€fling to Applic.nt, (9) 8ank oI B paym€nt lntomodhry may msko E.y roquiod cunency aonve6ion, A cancellalion or olher
reb]m ot rund! may Involvo a rov6rs6 cunoncy convarsbn. and Applicenl shall b6ar any r€leled loss, cha0€!. @sl! and €xpenses ol any kind
r6sLrlllng lrom such curonc, @nv6Bion.
3, Logaland Rogulatory ConFllrnco:86nk,lE amlatos and payment iBt€rmediades ale sublecl lo the laus, orda6. requests and guidelineg (each a
legulation") ol v3dou6 gov€mmenlBl. quasi-0ovemmeniel €nd sdl..€luatory eulhodties (6eci .n'euthoritts) 8nd 6l!0 to lh. resDeclivo polici6! and
procedlt!3 (oach e 'po cf) rdopted by Eaolq lB efli,late6 rnd psfn6nl intom8di8rigB rele$ng lo, wilholl limitstiofl: snli"monoy laund€dng:
counlenleftorism flnandno: 36cudly, dlplomallc, t6da, financiel, e@nomlc end olher embrrgoas and sancllons;court ordorsi lnvestlgallonsi lax6s:
tranleclion r€vi6w 8nd moiltodng; and roporting r.quir€monls. ln sooting to comdy wilh 6uch rogrlelion3 Bnd policJ€s, 8rnk, its sfUtisles 6nd/or
Pyment lntemedlgd$ m6y (!) suspend, rs,6cl or blo.* lh6 .€mlltanca; (b) r€sualn, d€duct, lmpound and./or lufi ov€r lo an authorlty. Apptic€nt'6
lunds in rospocl ol tha r6mltlance. incluling lrom Applloanl's ac.ountsi (c) repon lhe rernlfiaaco, Il9 dolattr and those of Appticant to one or morg
sulhoides;snd {d) lske orlolbe8r fiom tatino any ofi5r adion. Applic€nt 6hsll besr $s dsl ot sny dela, and losses.elatiog to any and al actions or
lorbeamnce lrom acton, 8ahk, ll3 amlial€s and pEymrnt intemadladar may not bo porminod lo dl6close lnlonna on .elali.g to 6c ons tsken in
raspecl olr€g atlois o h6l, policlss, immsdiately or.t€nytims.
4. Forcs ei€urel Bank may 6usPend or temlnelg Ihe sxoq)llon ol lhe remlltanc€ as a resull of any lorce maleuro ovsnt, lnduding, withqlt limltstion:
(a) chanle ln any rsgvlallon or ln lhe intenretatlon or onlorcsmonl olsny regulatlonl lb) scl, od€. or reguest ol6ny authority; (c) r€stdction or
impcnding restdclion on the ovailability, convenibility, cr€dit or kanrlerrtillty o, any clrelrcy; (d) feiture o, dsfault of sny pafnent intsmedbry; (e)
mlltqnclioo o, a computor ry{emi (0 lallu.e or dofrult o, 6 sewlcs grovi6od or v.rdor to Bin,( lg) any ,alfuro tn th6 t6n3dsslon ot, or
miscommunlcation with .sspost lo, lh6 r€mitlsn!6 lnstrucllon; or (h) sny other €v€nt b€yond 8!nkb .ersonable coitrot. Apptic€nt shrl bear the.tsk
olanydelayond loss* rolatlnolo s lorm ftalouloovs.t,
5, lnfom illo6 Olsclosuru: Appliaant consents to B6nk disdBing lo ils sfiili.t€s. lo it3 snd theh.o3p6ctiv€ 6ervlc. providsrs, insurers and prolessional
advisors and lo paymenllnto rcdiaier and aulhorillsa, ahda5 Equlrcd by regulation. thc totornetlon thst Applicsnt lumlshod tn the apptacaton.
6. Llmllltlor| ol tlrblllty: lndemnity, (e) aank snal not be lioble lo Applicaot lor any logs lhst Appticant may incur or otherwise sutter, however sfistng
or doscdbed end vrhalsvsr thg legalbasjs ot thc lleblltyin con.ectlon ilth B6nk's provision oflho Remmonco Ss&ics. unle$ the toss r,ras caused
by k6ud. gross nogllgenco or wlllful mBcondual on Eank's pai. g6nk 3he not bo obl€ lor€ny lndiract or consoqurnltst h3s or lo6s ol profit wi.thor
or not lhoy wers [ol6ao€abt6, lb) Bank shall not be responatbb for sny loss Applicant may $rtfer or tnqJr in conn€c on wfih any act o. omtsston of s
paF ent lnle.msdiary, (c) ApPllcanl lndemnlllo! Bank 6nd lB amlial.s oll drmend sgrlnst Ery end alllosses thst Ban* andor its alf.liales may lncu.
or oth€Mso 3ull6r ln @nn.cllon rvllh fie Remlflanco SeMce. exc€pt lo lhg oxtent, wlth oapact lo Eank or eny eriillel6, lhe lotsqs rssulied lrom ,r6ud.
grcss nogligsnce or willrul mlrcordud on lts pad.
7. F.es lnd Etpen3eB:
{a ) ll Applicanl has selsclsd I EN oo lhe Epdicstion: Sank shall seek lo collect any ,eos or expenses due o. payable by Applicsnt ,rom lio remittanco
amounl Bank msy ctrEg Appll.ant addtionat tee. ql ononse3 lor cjnce stion requ€lta, rstumad rcmittancgi €^d olher exceptional handting.
0sok's remlllsncc snd olhor l6os 6hstt b6 tn sc.ordance wtfi lts slsndsrd lodfla,
(b) l, Appllcant hss solocled OUR on lh6 spplicationi Bank may chaqeApplicsnt en additional r6miflanc! fee to covsr t€es payabte lo aipaymenl
inlemediary. &nk shall r66k to ln.lruct allp.yment intermGdlafiss to avold deducliDg arry rees or srpsns€s flom lho rcrnllanco emollnt, bu| Baol(
wlllnotbe r€sponsibto whera o psyment intermedtoryho3 ln€de a dqdudlon,
8. Anangemsnt wllh Peymont lntomsdtartos: Bint may enter lnto les end lntornation sharing Erangemonls wilh s payment tnlermediary in
connec{on wllh lho R6anitl6nca SoNlcc,
I lntorprcbton: Tho terlm '6u$rority", 'paFont lnlsmodiay', 'polioy'and 'rcgut6uon'have lheh Aa6lgned msantngs lhrolghout thes€ Terms, Th.
t'a.m 'afliliate' mcans Pdmo EEnl Ltmned or 6ny of tts sut,3tdtorjog, lncludln! thetr head ofita€ and brand|es,
I 0 Govarnlng (aw: Thes6 tems shall be govemsd by fie lar$ ol lhe judsdlcllon of Applia€nt a eccount for lh. romilance. Tho pdnies subml to the
non+rclusivejudsdtcti(M ot tho couG ot llre ,udsdi(tjon whose govemlng low oppltoB.
@ Prime Bank
I
2. Re.nltlsnc. Obllg.llon.: Appllarnl sgroes and aulhorizor 8a6t lo dobit upiront lhe romlll.noo smounl snd sny emolnl peyeblo lo connecUon wllh
(hs Romlllsnce Servic6 {rotn 6ny ol Applicanl B lccouflls wilh g!nk.
fra-fJt$ M"'
Sec Chapter 5 Para 2
TMID
Yaar FORM'TM'
Travel and Miscellaneous
Purposcr (othcr thsD lmport)
APP. 5 9
Inward Rcfer€nce
AD Cod.
APPLICATION TOR PERMISSTON UNDER FOREIGN EXCHANGE
REGULATION ACT, 1947 TO PURCHASE FORTIGN EXCHANGE
FOR THE PURPOSE SPECIFIED BELOW
To
'iha HaaJ 6J PIVtd
.P-.++r.. .. -e..a1'11 1ai9.194.......
Dh*{<c,....................i....,................
(N.mc & sddres! of thc BaEk to which application is made)
IA ewishtopurchase/remit..........91.Ir..Ar.4?-.9.rL2,-4..:...,0-9*..................,............forthcundor
(Amounl in figues and words srating currency)
mentiod€d purposc:.
I/Wc bereby dcclare that th€ statemcnts made by me/us on this form ale true and that l/we have Ilol
already obtained exchange.nor have l/we made any other application for the plrpose.
t A. For Trovel Purpotet:
I /Wc desire to travel tc. for the purposc of
Thejoumey rvill be ufldcrtakcn by.....,.
(c) Country of bener,"i"ry.Lh*r16h.d,,.....,,
(Name ofthe Air/Shipping Company)
My/Our Passport Nos, date & placc of issue arc given belowi
(a)
(b)
(c)
aB. For tttiscellaneous p0rpotes orher than lravel arul import;
(a) Reason ror paym*, .[*.hn.is,*l..snsl..A1on.+qm*^.&ft<...(.ltyg.iS*..N.q.'. ?.?.9L!.fl .
(b) Name & liddress of beneficiary trtllgad4 .flho+'..[shd ).g,r.g-1.,.? 9.(.*.4q r -or.S$ /'"*b."*'^nh loz-1 o
fi1 Md* I
Signalure, Nome artd .4dtlrcss
ol'the Applicdnt
Contd...P/2
Ref. rrD codel Rcf, I
Declaratlon to bc signed by thc travcller/rcmltter
(a) Thal ltu crccognisc lhat in tbe everrt o"ny.misrcptlsent8tioi::-:llp.t::'':" "f ""y maletialfact'
' ' Uw" ,rr"tt U" tiiUle to action undci the Forcign Exchange Rcdulation Act' 1947'
(b) That thc foreign exchaoge releascd ro me/us shall be used for cxpenses incuned by means irl
foreign country/countrics for
'(i) my/our living and uavqlling arPcDses for busiocss purposrs'
t(ii) my/gur cntoute expenscs for kavel sbroad'
: '(iii) my/our livinf, expcnscs and mcdicsl trsatmcnt'
(c) ywe an are awarc lhat etchsn8e issued lo me'/us under this form for lrav'l purposes rn'y only
be takcn our by mc/us on my/out dapatture from Bangladcsh and may not br scnt out by post or
through (he m;dium of any other person ot by any other rncaos'
Prgc-2
(d) Thal if lhc t,avel has not bccD undrrtaker for the purposc mentioned abovc, or if any unsp€nt
foreign exchangE remaining in my/ouf possessioD o, 8t my /our disposal or whirh could not bc
utjlised for the Purposc fo, which it wa$ gnntcd, will bc sold by mc/us to alr Authorised Dealcr in
forcign exchangc in Ban gladcsh immedialely on my/our r€turn to Baogladesh'
'(c) l/we dcclare thal the paymenl nlcDtioned aga inst'b'8bove is due lo bs made by lne/us for v'hich
documcntary cvidenie is cncloscd and assumc fulf rcsP onsibility for mmPlYing vith thc
provisions of rhe Forcign E,(cha[ge Rcgulation Act, 194? and des' orders and directive's issued
Sec Cbapter 5 Pars 2
lhctcunder
in ternrs ofPara
approvElNo. ...
/tr. W
APP. 5 9
olth. qplicdat
Cbrtificate of upprovol ofthcBanglsdssl Bank (if rcquircd)'
Mlid for jd (lhiny) days frorrr the dats of approva[
Scal & Signature ofthe Bangladesh Barik Offi cial
' (Ce'tilicate by Authorlscd Dell€r)
'(n) Wc havc issucd Notcs &Coins .- "" T/C " " "" " UC
Toul..:.,.... .. ... .... .. as pcr Bangladcsh Bank approval doted "" - -""''- """ "" "" " and
endorsed rhc amolnl relcased i|r thc travelle/s possport after cxsmining the ti.ket covcring the passage'
,O) W€ have effccled reminangc of..,.,...,..,....'
.......Chaprcr..
(Slatc amounl)
.,.............of GFETiBan8ladesh Bpnk's
(TTA4T/Draft)
Contd...P/3
dtrted
Date of approYal.
Para f See ChaPter 5
P.g€-3 APP. 5 9
Cage tobe cornplcted by Authorised Dealcr indicodng
Bangladesh Bank
Codc No. as per Code list circulated by thc
Amount jn foreign currency Currsncy Cttegory Purpose
Couutry of
bcncficiary
Month
I/ we hereby carri0 having reoeivsd thc exchanEe issued lo me/us as above
lrl
Signature and StanP o/ the
Authot'ised Dealer
Sigtdaure(s) ol th' APqlicont(s)
I
I
e"'
I
r Srike out itcms not aPplicablc