FORM A1

(For Import Payment Only)

(Application for Remittance in Foreign Currency)
Amount
Remitted _US Dollars______$4295.00____________________ Serial No. ___________________________
Currency Amount (for use of Reserve Bank of India)
A.D. Code No. 06910204-6000009
Equivalent to Rupees ____________________ Form No. ___________________________
(To be completed by Authorised Dealer) (To be filled by Authorised Dealer)_______

I/ We wish to purchase ____US Dollars________Four Thousand two hundred and ninety five only____
(Name of currency) (Amount in words)

through _______________________________________________________________________________________________________ or payment to

(Name and address of the Authorised Dealer)
Avnet Asia Pte. Ltd, 151 LORONG CHUAN ,NEW TECH PARK,#06-03, Singapore 556741 payment of
(Name and address of the Beneficiary of the remittance)
imports into India, detailed below:

Details of goods imported or to be imported into India

Section A: Import Licence/Open General Licence Particulars
O.G.L. __________________ __________________ __________________
NUMBER PART SCHEDULE SERIAL NUMBER
IMPORT LICENCE DATE OF ISSUE DATE OF EXPIRY FACE AMOUNT T0 BALANCE
PREFIXES LICENCE SUFFIXES Date Month Year Date Month Year VALUE OF BE OUT-
NO. LICENCE ENDORSED STANDING ON
1 2 1 2 3 4 5 (IN Rs. ) @ THE
LICENCE
AFTER THE
REMITTANCE

@ Actual Amount endorsed in Rupees against each licence involved should be stated under this column.
NOTE: If more than one licence is involved, particulars of all licences should be furnished in inadequate, a separate statement may be attached. The
amount utilised against each licence should invariably be indicated.
Section B: Import particulars
Invoice Details Qty of Description of goods BTN Country of Country from Mode of Date of
Invoice Terms Currency Amount goods Classifica- origin of goods which goods Shipment Shipment (if
No. and (c.i.f.) Tions are consigned (air, sea, not known
post, rail, approximate
Date F.O.B.
river, date)
c.& f. transport
etc. etc.

INTERN
EF-ISE-SYSTEM-NL ET WEB
1 UNITED BASED
(PRODUCT: SOFTWARE)
STATES DELIVE
MANUFACTURER RY OF
:XILINX INC. SOFTW
ARE
(NO
PHYSIC
AL
SHIPM
ENT)
 Section C: Other particulars

1. Details of forward purchase contract if any, _____________________ _________________ ______________

booked against the import. (No. & Date of Contract) (Currency and Amount (Balance under
of contract) the contract)
2. If remittance to be made is less than invoice value reason ____________________________________
therefore (i.e. part remittance, instalment etc.) ____________________________________

I/We hereby declare that the statement made by me/us on this form are true and that I/We have not applied for an authorisation
through any other bank.
I/We declare and also understand that the foreign exchange to be acquired by me/us persuant to this application shall be used by
me/us only for the purpose for which it is acquired and that the conditions subject to which the exchange is granted will be
complied with.

Name of Applicant(s) : Nationality of Applicant(s)

Address of Applicant(s) : For .

Import Code No. :

Date: ___________ AUTHORISED SIGNATORY.

Note: for remittances covering intermediary trade. Form A2 should be used.

 DECLARATION – CUM- UNDERTAKING
(UNDER SEC. 10(5), CHAPT III OF THE FOREIGN EXCHANGE MANAGEMENT ACT, 1999)
I/We hereby declare that the transaction(s), the details of which are specifically mentioned in the schedule hereunder does not involve and is not designed
for the purpose of any contravention or evasion of the provisions of the aforesaid Act or of any rule, regulation, notification, direction or order made
thereunder.

I/We also hereby agree and undertake to give such information/documents, before the Bank undertakes the transaction(s) and as may be required from
time to time as will reasonably satisfy you about the transaction(s) in terms of the terms of the above declaration.

I/We also understand that if I/We refuse to comply with any such requirement or make unsatisfactory compliance therewith, the Bank shall refuse in
writing to undertake the transaction and shall if it has reason to believe that any contravention/evasion is contemplated by me/us report the manner to
Reserve Bank.

I / We further declare that the undersigned has/have the authority to give this declaration and undertaking on behalf of the firm / company.

Place : Mumbai
Date : __________
•Applicable when the declaration / undertaking is signed on behalf of the firm / company.
Declaration to be furnished by Applicant(s)

I/We declare that

(a)the goods to which this applicant relates have been* imported into India on my/our account*
will be
(b)the import is on behalf @ _______________________________________________________________________ and

(c)the invoice value of the goods which is declared on this form is the value of the goods imported* into India.
to be imported *

If the import I/We such the relative Custom-stamped Exchange Control Copy of Bill of Entry*
has been made Post Parcel Wrapper (for Import by post*)
or
If the import I/We undertake to produce within three months to the authorised dealer the relative Custom-stamped Exchange
is to be made Control copy of Bill of Entry* Post Parcel Wrapper
(for imports by post)*
*Stike out item not applicable

@ Where the import is on behalf of Central/State Government Department or a Company owned by Central/State Government,
Statutory Corporation Local Body, etc. the name of Government Department Corporation etc. should be stated.

For

AUTHORISED SIGNATORY.
Date: ___________ Signature of Applicant(s)

Space for comments of the Authorisd Dealer while forwarding the application to the Reserve Bank of India for approval Reference to Exchange
Control Manual paragraph, A.D. circular, in terms of which the reference is made should invariably be cited. If any remittance application on
account of the same import was required to the Reserve Bank earlier, reference to the last cocrrespondence/approval should also be cited.

Date: ______________ (Stamp and Signature of Authorised Dealer)

 Certificate to be furnished by Authorized Dealer (Importers Banker)
We hereby certify that,
(a) this payment is

Put a (i) an advance remittance.

(ii) in retirement of bills under Letter of Credit opened through us.

(iii) against documents received through our medium for collection.

(iv) on account documents received by the applicant(s) against undertaking furnished by the
letter to submit Customs-stamped Exchange Control Copy of Bill of Entry/Post Parcel
Wrapper within three months

(v)on account of documents received direct by the applicant(s) against Custom-Stamped

Exchange Control Copy of Bill of Entry/Post Parcel Wrapper (attached submitted by
the letter)
(vi)
(any other case to be explained)
(b) all the Exchange Control Regulations applicable to the remittance have been complied with
(c)the payment to the suppliers of the goods has been* made through ______________________________________
will be (Name and address of the foreign Bank)
We also certify/undertake that the relevant Customs-stamped Exchange Control Copy of Bill of Entry or Post Parcel Wrapper
* shall be verified by us within three months (vide certificate (a) (ii) and (iii) above)
* has been verified (vide certificate (a) (v) above)
shall be obtained from the applicant(s) and forwarded to the Reserve Bank within three months (vide certificate (a)
(i) and (iv) above)
*strike out item not applicable

Stamp and Signature of Authorised Dealer)