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PERIOD : _____________________________________________________________________
AUTHORIZED DEALER : ________________________________________________________
CURRENCY : __________________________________________________________________
| Name and adress of Non resident bank whose account with A.D is debited | Name and adress of bank whose account is credited | Name of A.D with whom the account credited is kept | Amount Transferred | Country Code | Purpose | ||
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7010 |
| * Total | |||||||
* Total will be entered against item No 3 of purchase side of relevant S-4/S-5 statements
Stamp and Signature of Authorized Dealer
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