/
prc,r! iir ri uri^0 ELoc( L.[06
qoaso {v/ ) d,'d .pprBde
'ridicd.3 msddory r di,arid. ro h. pond.d
o Applicant' (Remitler) lnlormation
Name or Apprcant. fl.u-rrrh..lio$l.*y..9.*d4$.-t*+v*. Rererence No. ....-.....
tTlzl@!tr t2lolzLel
c 9L"7.3.3-:
Charges Oebil &C Nc '
D Pr..* t,a ir u. r"."--. oJi*"o,"r
o Remittance Amount
P.a*ddC*ft^cy.r &d tle
cur6ncy or Remittancs ' ..!-S.P......
a b ]i Th F , o a
N N "4fu '11 0 v
{.-/ S t>
o Aeo!^r No. / IBAN . .3.!.9-.9,a 6
Recipienls Bank Delails
o
D sH^-Locar chiB.! bdnp hy,cmlhpr E overseas by bFncn.iary
LTOUR.AII ro.€l a.o ov€rsoas crarges bohe by ,.r,n6r
L_l SLN.arlrocar and ove.sc.s cla,€es bore b, beie[c,ary
Amounl to be Remnred'
Counrry '
swrFT/crea,l,s code. ..BE.T.K.T:.H..p..X.
Add,sss ti:; W*3A;A-;B"Gr..-K'
lntermedl€ry Bank lnlormation {Option6l}
tTiill"i:-"nav-+qm. Fh*,ls,rd)tu., u+4'. .
lo.6€...+!.,*r..4.6.r. ,5EHhe.a-n.{i.t.3ot
Ro qd .,.5+n1$f eaqRs?I1..49.2, 7.q
cour,.y' :%;r,ts;J . ... .. .
Country '
o Paynonl Oer.ils (e g lnvoice, Fp,erence, c1c...,. )
...I-n..,,-0.ie.e,.....t}i.p........!9.a..A.6.3.
o
o Appllcant's Signaturo
SWIFT / Clearing Code
trtr EN
Puroose of Remittanca
flaehnieo.tr 4a3 l{ 6"y164aaa"} Fca
,;;.;,.;,":.,.;":,;;;;;";;:#;;";;;;;;;;;;;.;;"";;;:;.,." n6na.@nr.q.! ch-,,o,cNy, hd6 JDdan Mdayca p*,ana!
, tt" N--
o For lnternaluse Only
Pq,ned RcrcaM;................,......,.....,...,.-,..,,.,..,.
l.nitrMc.'ppri.nonis3.c,i'c,id'ld
la, or .rriim.rtr krcwrdsc, @@!.r., &ar'mrim ro be hn(sd h ruisdidi ., ^oori.a^! .6ood.
.3 rslNi! Ldr iupEd.r4'hicc3pdbr6.
Aaouad ,!,ee b b. h@nd by rh. R€n rra'ro Sttui.e l.m3,con
IJ in app,op,i.r6 chel(.borl*) ns
L ll oo
Df
!
@ rrime Bank
Tt-l rT-t
Reclplent's (Bcnericlary) lnrormallon
4,
fBnr
n
Remittance Service Terms
These leins supplefirenr lhe exlsllng lerms and aondirions govemlng Appticanfs ac.ounl used lor lhe Remitsnco seNlce To fie exlenl ol sny
idcooslgency. lhese lerms shsll proveil.
1. Remlrince serytcei (a) Bsnk sholl use reasonable care and 5k ln providing lho Rsmlttance SeMce. (b) Unless s laler dale is sPeqlied in lhe
appucalion, Bank sha seck lo erecute lhe remilanm on lhe blsiness day lhal Sank recches the remillance applicalion. il received pdor lo lhe
oppllc€ble cU o[timc al Eonk.s seMce localion: olhe^rise, Bonk shslls€ek toerecul€ the romiltance on the nexl business day. The romitEncc may
taio tongcr than one bustness day to e)(ecu1e. (c) Bsnk msy insrruct il afffiare, anolher bank. , cleati.g houso. a paymenl. dearing o, setJemed
system or otner paymenr tnrsrmedlary (each a 'payment lntermediary') in lhe erecdion ol the r€millanc€. Eadr parnenl lnlemediary may rcly on
Applicants remi[ance tnstructiotrs os tfdnecled lo it. {d) Sankmaynot execule lhe rsmilian.€ ilApplicrnfs 6cc6lJnt has insumcienl lunds, (o) Upof,
Applicnnt s ffinen requesl. Bsnk shall use reasonrble ellons lo cancel or llop lhe rernillance; however, E€nk shall nol be responsitrlo il tho
rerntrrance ls executed, {0 Aant msy act on lncomplere or lnconsistenl lnstruc ons il Bank rsasoo6bly belioves lhal il c€n complele or danry s'Jch
lntoimation wlrhou! retsr,ing lo Apptica.t, (9) Bank ol a paymeni lntsflnediary mry mEte any required cunency conversion. A cancellalion or olher
rerlm o{ tunds may lnvotv€ a roverse cufiency aonyerslon. and Applicinl shall bear any relal€d loss. c,larges. cosls and expens€s ol any kind
resulling lrom such c!noncy conversion.
?. Remhancs Obllgaltons: Ap9ticant agrees and authonzos Eank lo debilup,ront lhe remiuaoce amornl and any amounl payable in conneclion wilh
tlre Rernillance Seryicelrom 8nv o,Applicanl s ac{ounls wilh gsnti
Lcqat .nd ReEutatory Compllanco: Bant.lts atfiliales and paymenr inr€medianerare Subjecl lolhe laws. ord6as,Iequesls and guidelines{each t
legltation") o,v6dous govsmmsntat! quasi-govemmenlal ,nd sd,-regulatory authorilios (each an'aulhoriy) 6nd olso to Ua respeclive policies and
procedu,es {each s 'po,icy'} edopted by Bank, iB sniliale6 snd paymsni IntEmedisies rclating to. withoot lim(allon: anll"rnoney laundsdng;
coutrrerlefl6is,n lirandng: Bocuity, diplomatlc. t ade, finanoal, economic and olher emb!.9o6s 8nd $ndion3;court ordersi Invesligalions; laxesi
t.ansaction r€view End monltodng; 6nd reporting rcquhsmenlr. ln s66ling to comply lyilh 6uch regulalions snd policlss, 8ank. ius amliates andror
pay,ncnr lntermedlsriss msy {6) suspend, reiecl or btocr( lhs r€mlttancs: (b) r6s[aln, deducl, lmpound and/d lum ov€r Io an aulho.lly. ApPlic.nt's
tunds in respect ol lhe r€mlttance. induding trom Appltcants ac.ounB; (c) repon he ,EmiIrnce, lls delalls and lhose ol Applicanl to one or more
aurho,iries;!nd (d) rske or lotueor f.om raking sny orhor aciion. Applicant shallbe3r iho dsl ol any delay and losses,€lalin0 to sny end allaclions or
lorbearance rrorn acllon. Bank, lrs sflllisle3 and pafnent inlermediafies may nol bs P€minod to disdos€ lnlornallon .elaling to ac{ons taken in
respecl ol regulalloos or lhok polkles. immsdaat€ly or st any lim€.
4. Forc6 Majourc: Eank may 6uspe,rd o, terminalo lhe 6x6culion ot lh6 remlltance as a resull of any lorce maleuo event, lnduding, $ithoul limltation:
lel chrnge ln any ,egulalloo or In lhe interpretelion or 6nlorcem6nt ol sny regulationi (b) acl, od6r or requesl ol sny authodly; (c) resliclion or
impendinO reslncion on lhe 6v6ilabilily, conlenibility, credilor lrsnsferabiliry o, sny cunencyj {d) fsilure or deraull orany payrned intemediaryi (e)
.nallunclion ot a compulor syslem: ll) hilure or delault ol a seMce provlded or vendor 1o Bank: 19) any lallurc ln lho lransmlsslofi o!. or
mlscommuoicalion wi(h respoct to,lh6 remitlanoo lnsrruclloni or (h)enyorher evenl boyond 8!nl! Gasonablo contrd. Appliclnt shallbear lhe dst
olany delay and loises rulo0hglo a lorcc maleur€ eve[t.
5. lniormition Ois.lo8ur.: Appllcanl cons?ntj to B6^k disclosing lo its atfitiales, toib End their.espective servi@ p.ovldefs. insurcc rnd prclessional
advisors and lo paymenl Intonhedia des and aulhorillos. and a9 Equircd by regula on, the inlonnatlon lhal Applicant lumlshed ln lhe applicalion.
6. Llmltstloh ot Llrbllltyr lndelnnny, (6)Bank shallnol bc liable lo Applicanl,o. sny loss lhal Appliconl may incrrr or othe&lse $rller, howeveradsing
or dosclbed and r'halBvor lhe lcgolbasls o, the lbbllity in conneclion wllh Eank's provision ollhe Remltla.co Servic6. unless lhe loss was caused
by,6ud. grcss negligenc€ orwllful iniscoMuct on gank's pa'l. gsnk shrllnot be l]6ue lor any lndirecl or consequ€nlial loss or loss of pro'it whelher
or nol lheywere lorosee8ble, (b) Esnk shallnot be responsible ror sny loss Applic€nl may suller orlncur in connocllon wilh any acl or omisslon ol e
paynenl inlemrediary, (clApplicanl indemhl,ios Eanl and lts amlales on demand againsl any snd all losses that ganl andror ils alfiliales may lnd,
or olherwls6 sull6r ln connacllon whh lhe Reftlttanco SoMce, except to lhe erenl \yilh r6sp6al lo Bank or eny 6lfillal6, lhe losses resulled lrom lraud,
gross negligcnce or raill,ul mlsconducl on lls p8rl.
7. Fees end Erpense6:
(a) l, Applicatrl has sele€led BEN on lhe 6pplication: Bank shell seel to collecl sny,ees o. erpsnses due or payable by Applicant lrcrn the remillance
amounl Sanl may chargs Appllcanl addilonal tees or expenses lor cencellarion requesrs, relumed remillancei and ouler e)cepllonal handljng.
Ssnk s remittanco and olher,6€s ihallbeln €ctordencewlth lts standard l8dlls. rj
(b) lfApplicant has seleclod OUR on the appttcrtioot ABnk may ch6me Appticsnt en eddi$onat @mittsnce tee to covs. rees psyabt€ lo a patnent
intemediary. &nk shalli66k to lnslructall paymant intermediades to avoid deduding any tees or erpens€s trcm lhe remtilance amount, bul Eanll
willnolbe rosponsibb$here s psymenl inlemedlaryh8s made a deducllon,
8. Arangemont wlth P.ymonl lntorm.dlarle!: gank may ente, lnlo lee and lntomaiion Bharing arangemenls vyith a prymenl lnlermediary in
conneclloo wilh lho R€millanca Seryicc,
9 lnrorprebtloni The tems 'authoitf, 'payment lnlorm.diad, 'poticy' and 'regulErlon' have lh6irAssigned meanlngs lhrorrghout lheso Tems. Ths
lerm 'amliale' n crn3 Primo Ba,rk Llmlted or sny of its subsldlados, lndudlng thek heod omces snd blandle3.
n.uq @ Prime Bank
I
I 0. Govo.nlng Low: Theso lerms shall be govs'ned by lhe laws o, lhs ju,iidiclion o, Applicant s ac.ounl foa lie lemlttaoce. Ths panies submll to tho
non-ercllrslve judsdlclion ol tho courts ot the,udsd;clion whose loverning lEw epplles.
N,"-
Para 2
TMID
AD Code Rci FORM'TM'
Travel snd Miscellaneous
Purposes (other thsD import)
APP. 5 9
Inward R€ference
AD Code Re(
for thc under
To
-lk-.-qksc. d...*-m q ...
P...nl.me...Brlnl.q.. .Hn.r.tssl......
Ohctse..
(Namc & address ofthe Bank to which application is made)
I/We wish to purchase/remit ........-qF.I.1..'3-,.-q.9.**.-?-?.9.:...O-.9
(Amounl in tigll,cs flnd words stating r:rrrrcncy)
mentioned purpose:-
I/Wc hcrcby dcclarc that the siatements made by me/us on this form are true aod lhal I/we have nol
already obtained exchange.por have l/we made any othe! application for the purpose.
t h. For Truvel Purpose.t:
I /W9 desirc to tBvel to for the purpose of
Tbe joumey rvill be underlakcn by .,...,..
(c ) Corxrtry o f b enefi c i a ry ..,.40:1.\41 -6-.:...,
(Name ofthe Airlshipping Company)
My/Our Passport Nos, date & placc of issuc arc givcn bclow:-
(a)
(b)
(")
+8. For ntiscellaneous purposes other than lrovcl and itnport. - -
1"; n"",on ro,p"y.";,T-A;i.*{;^d Us.ln$4{,*+Fr.-....thyg.l*.Ng.t..l?-9.19.{ ..
(b) Name & address orueneficiary Atvr,eh..(lfpr.lq'.dt4r-...t.ta,.70-6$.fiu.4-o.rSq.n{tP.l5S!!!).la21a '
,+t.Lltr &e"' ,/"
Signalure, Name aud Adlress
ol the Applicdnt
Contd...P/2
Sec Chapter 5
APPLICA ION FOR PERMISSION UNDER FOREIGN EXCHANGE
REGULA IONACT, 1947 TO PURCHASE FORI,IGN EXCHANGE
FOR T}IE PURI'OSE SPECIFIED BELOW
Declrradon to bc siSned by thc traicller/tcmlfle'.
(a) lhal l/wc tecognisc lhal in lheevelllofany ntisrcprescntation or suppression ofany material fact'
uwc sr,att uc ti]ulc to acrion undci thc Forcign Exchangc Rcgulation Acl, )94?
(b) Thal lhc foreign exchange releascd to mc/us shall be used tbr cxpenses incurrcd by means in
fot ciEn counlry/countrics for
'(i) ,nylour living and travelling erpcrlies for busjncss purposes'
i(ii) mylour cnroulc cxpenses for travel abroad'
APP. 5 9
:'(iii) my/our living expcnscs and mcdical treatmcnt
(c) ywe arlare owara lhal exchsnge issued lo me/us uoder tlis foIm for lravel purposes moy ooly
bc rakcn out bY mc/us on mY/oul dePaltute frcm B angladcsh and may not be scnl out by posl or
through lhe nrcdl um of any olher person or by any othet mcatls
(d) Thst if lh. tra vel has not bccn undettak for the purpose mentiooed abovc, or if anY unsPent
foreign cxchange remainlng io my/our posscssion ot ot my/our disposal or which could rlol bc
ulilised for lhe Purposc for wh ich it was grsntcd, will bc sold bY De/us to an Authorised Oealcr in
forcign exchangc in Bangladesh immedialelY on mYlour relurn lo Bangladesh.
'(c) l/We dcclarc $at the PaYm enl nrcntioned aEoinst 'b' above is duc lo bc made bY melus for $'hich
documcntary cvidencc is cncloscd and assume full' rcsp onsibility for complYi ng wilh t)lc
provisions of the Forcign Exchange Rcgula(ioll Act, 194? and rules, ordors and ves issued
lhctcundcr M,"
Signatu the opPlican,
' (cettifi;ate by Authorlsod Dealer)
'(r) Wc havc issucd Nol.s & Coins " - " """"T/C " " ""UC
Toul..:....-................ as pcr Bangladcsh Bank approval dated ""'
"rOo,""a th" "*ouo, ,clcused ir the tEvelle/s passport aftcl cxumioitlg the ticket
r(b) wc have effccled reminaogc of
in ternrs ofPara ,.....
approvalNo. ..... ...
(Slalc amounl)
.......Cbaptcr.............,......of GFET/Bangladesh Bank s
..... dated.......... . .. ..by.'. " " "" on- " "" " '
.-................'.'.. and
covcring thc Passage'
......(TTIMT/Droft)
Contd...P/3
Para 2 Sec ChaPler 5
Cbni6cate of approvol ofthc Bang'ladesh Bank (ifrequircd)
--"ry"iia r- l'ti t,rtit y) doys frorn the datc ofspprovall
a&sh Barik Ofllcial
Scrl & Signature of lhe Bangl
Pog.-2
Datc of rpproval.
Para 2'
See ChaPter 5
Pagc.3 9 APP. 5
Cage to be completed by Authorised Dealer indic0ting
Bangladcsh Bar <'
Codc No, as per Codc lis! citculated by lhc
Anount in foreign currcncy
CurrencY
Catcgory Purposc
CouDlry 0f
bcncficiatY
Morth
I/ wc hereby cefliry having rcceived lhe exchange issued ro mr:/us as abovc'
/fi VA
Sitlnatrrc on(l Sta'nP oI thc
Aulhot'isel Dealct
Signature(s) of the APPlicant(s)
, strike out items not apPlicable
I
N
I
t