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PERIOD : __________________________________________________________________________________________
AUTHORISED DEALER : ______________________________________________________________________________
CURRENCY PURCHASED : _________________________________________________________________
| Name and address of overseas bank / Correspondent to whose account the rupee equivalent is | Foreign Currency Amount | @ | Rupee Amount | Purpose |
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| Million | Th. | Units | Country Code | Purpose | Million | Th. | Units | ||
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6010 |
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3011 |
| Total |
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* Total of foreign currency will agree with the amount listed against item '3' of purchase side of the relevant S-1 statement
** Total of Rupee amount will be entered against item '5' of sale side ofS-4/S-5 statement @ Code number of the country from whom foreign currency is purchased should be given
Stamp and Signature of Authorised Dealer
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