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PERIOD : _____________________________________________________________________
AUTHORIZED DEALER : ________________________________________________________
CURRENCY Non-resident Rupee : __________________________________________________
FOREIGN CURRENCY : __________________________________________________________
| Name and address of the bank branch and correspondent whose account is debited. | Rupee Amount | @ Country Code | Purpose | Foreign Currency Amount | Purpose | ||||
| Million | Th. | Units | Million | Th. | Units | ||||
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7011 |
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2010 |
| Total | |||||||||
* Total of Rupee amount will be entered against item '4' of Receipt side of the relevant S-4/S-5 statements
** Foreign currency amount must agree with the amount listed against item '4' of sale side of the relevant S-1 @ Code number of the country to whom foreign currency is sold should be given
Stamp and Signature of Authorized Dealer
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