FORM 'TM'
Travel and Miscellaneous
Purposes (other than import)
APPLICATION FOR PERMISSION UNDER FOREIGN EXCHANGE
REGULATION ACT, 1947 TO PURCHASE FOREIGN EXCHANGE
FOR THE PURPOSE SPECIFIED BELOW
To
The Manager
HSBC Bank Limited
Management Office, Level 4, Shanta Western Tower 186 Bir Uttam Mir Shawkat Ali Road Tejgaon Industrial Area, Dhaka 1208
(Name & address of the Bank to which application is made)
I/We wish to purchase/remit BDT 392,500.00 (Three Lac Ninety Two Thousand Five Hundred) for the under
(Amount in figures and words stating currency)
mentioned purpose:-
I/We hereby declare that the statements made by me/us on this form are true and that I/we have not
already obtained exchange nor have I/we made any other application for the purpose.
* A. For Travel Purposes:
I /We desire to travel to ............................................. for the purpose of ..................................................
The journey will be undertaken by ...................................................................................................
(Name of the Air/Shipping Company)
My/Our Passport Nos, date & place of issue are given below:-
(a)
(b)
(c)
*B. For miscellaneous purposes other than travel and import:
(a) Reason for payment surplus amount of Share Capital Purchase Money
(b) Name & address of beneficiary NICCA CHEMICAL CO., LTD. (23-1, 4-CHOME, BUNKYO, FUKUI-CITY, FUKUI, 910-8670, Japan
(c) Country of beneficiary Japan
Signature, Name and Address
of the Applicant
Contd...P/2
9 APP. 5 Para 2 See Chapter 5
TM ID
AD Code Ref. Year
Inward Reference
AD Code Ref. Year
✓
Kotaro Takeuchi
3rd floor, Suvastu Suraiya Trade Center, 57 Kemal
Ataturk Ave, Dhaka 1213
Declaration to be signed by the traveller/remitter
(a) That I/we recognise that in the event of any misrepresentation or suppression of any material fact,
I/we shall be liable to action under the Foreign Exchange Regulation Act, 1947.
(b) That the foreign exchange released to me/us shall be used for expenses incurred by means in
foreign country/countries for
*(i) my/our living and travelling expenses for business purposes.
*(ii) my/our enroute expenses for travel abroad.
*(iii) my/our living expenses and medical treatment.
(c) I/We am/are aware that exchange issued to me/us under this form for travel purposes may only
be taken out by me/us on my/our departure from Bangladesh and may not be sent out by post or
through the medium of any other person or by any other means.
(d) That if the travel has not been undertaken for the purpose mentioned above, or if any unspent
foreign exchange remaining in my/our possession or at my/our disposal or which could not be
utilised for the purpose for which it was granted, will be sold by me/us to an Authorised Dealer in
foreign exchange in Bangladesh immediately on my/our return to Bangladesh.
*(e) I/We declare that the payment mentioned against 'b' above is due to be made by me/us for which
documentary evidence is enclosed and assume full responsibility for complying with the
provisions of the Foreign Exchange Regulation Act, 1947 and rules, orders and directives issued
thereunder.
Signature of the applicant
(Certificate by Authorised Dealer)
*(a) We have issued Notes & Coins ..............................T/C ........................... L/C ...............................
Total........................ as per Bangladesh Bank approval dated.................................................... and
endorsed the amount released in the traveller's passport after examining the ticket covering the passage.
*(b) We have effected remittance of ........................................................................................................
(State amount)
in terms of Para ..................Chapter....................of GFET/Bangladesh Bank's
approval No. .................... dated ....................by.......................on............................(TT/MT/Draft)
Contd...P/3
Certificate of approval of the Bangladesh Bank (if required).
[Valid for 30 (thirty) days from the date of approval]
Date of approval. Seal & Signature of the Bangladesh Bank Official
9 APP. 5 Para 2 See Chapter 5 Page-2
✓
Cage to be completed by Authorised Dealer indicating Code No. as per Code list circulated by the
Bangladesh Bank.
Month
Country of
beneficiary
Purpose Category Currency Amount in foreign currency
Signature and Stamp of the
Authorised Dealer
I/ we hereby certify having received the exchange issued to me/us as above.
Signature(s) of the Applicant(s)
* Strike out items not applicable
9 APP. 5 Para 2 See Chapter 5 Page-3
✓