BANK OF INDIA DATE_________________

3 rue Scribe,

75009 PARIS SCROLL NO.___________

A UTLISER POUR LES EUROS / USE FOR EUROS ONLY

DEMANDE DE TRANSFERT/ APPLICATION FOR TRANSFER OF FUNDS

Par avion / By Airmail--Par telex / By telex --selon les details suivants / as per details below:

It is understood that Bank of India, Paris shall effect the remittance through one of its branches/correspondents chosen by them to facilitate the transfer, however it undertakes no responsibility for delays occurring in receipt of funds by ultimate beneficiary due to postal delays, communication breakdowns or by its choosing a particular branch or a correspondent for effecting the transfer.

I also declare on the reverse of this application, the serial numbers of all the 500 notes being deposited by me. In the event of any of these notes being found to be fake notes, I undertake to make good the loss to you.

X 5

 

X 10

 

X 20

 

X 50

 

DD / MT / TT NO. CADRE RESERVE A LA BANQUE / FOR BANK USE

Amount (FCY)

 

Cours de negotiation de devise / Rate of exchange

Contre-valeur en EUROS / Equivalent in EUROS

 

Notre frais / Our Charges .

__________________________

TOTAL RECEIVED .

________________________

 

 

 

 

Signature of Cashier Signature of Checking Official

 

BENEFICAIRE / BENEFICIARY

 

Nom / Name :

 

Adresse / Address :

 

 

 

Compte No. :

 

Son compte chez / in account with :

 

 

 

Montant / Amount : EUR

Montant en letters / Amount in words EUR ..

Motif / Purpose :

I declare that this remittance is made out of my bonafide legal sources not involving any unlawful activities .and I shall provide proof whenever required.. The beneficiary of this remittance is personally known to me and the proceeds of this remittance will not be used for any unlawful activity.

 

Signature :

 

BRANCH

 

D D M T T T

 

 

X 500

X 200

X 100

 

 

 

COINS

 

TOTAL

 

VERSEMENT DESPECES / DETAILS DES ESPECES VERSEES BILLETS ( EUROS )

 

 

 

DONNEUR DORDRE / APPLICANT

 

Nom / Name :

 

Adresse / Address :

 

 

 

Telephone :

 

No de carte de sejour /

carte de identite :