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To ensure that your payment is received by your institution without any delays,
please follow the instructions below:
Due to Indian regulations, in order to complete your payment you will need to present the attached Outward
Remittance Request Form along with proof of identity and address at a local ICICI Bank branch.
To find the nearest ICICI Bank branch, please use their branch locator by clicking Here.
1.rint the !utward "emittance "e#uest and ayment Instructions forms
$.%ill out the !utward "emittance "e#uest form. &ote that much of the information has been pre'populated for
your con(enience. Below are the items which are to be completed by the person making the I&" payment
)remitter*. t is important that all items below are completed in full to ensure efficient processin! of your
payment.
"ection #: The remitter fills in their &ame, +ddress and hone &umber.
"ection $%b: %ill in the designated amount of I&" shown on the attached instructions in words. ,nsure
that the amount populated in numbers as well.
"ection &: '' (''O)*T +O,-.R" O*,Y / The remitter pro(ides the ICICI I&" account number to
be debited for the payment. )&on'ICICI account holders see Item - below*
"ection 0: ro(ide the .tudent &ame, .tudent ID and Country of .tudy +broad.
"ection 1: lease ensure that the ICICI representati(e includes the displayed Reference *umber with
the wire payment.
"i!nature: The remitter signs and dates the !utward "emittance "e#uest at the end of the Declaration
on age /.
/.Take the printed0signed documents and present your proof of identify and address for (erification by ICICI
Bank1. The ICICI representati(e will complete the 23C Certification with the remitter as applicable. +cceptable
identification includes4
Proof of Identity Proof of Address
PAN Card Passport
Voter ID Card Telephone Bill
Driving License Electricity Bill
Government ID Card Bank tatement !ith che"#e
Photo ration card Certi$icate%ID Card% avings Pass Book iss#ed &y Post
'$$ice
enior citi(en ID card Latest premi#m receipt o$ any li$e ins#rance co
Passport Cons#mer gas connection card%&ook%Pipe gas &ill
Leave%Lease and License Agreement
-.&on'ICICI account holders will transfer funds locally from their respecti(e bank accounts to ICICI Bank pool
account through &,%T0"T5. as per the details mentioned below4
Beneficiary &ame4 !utward "emittance ool +ccount
+ccount &umber4 66/7.8!"CBC
I%.C Code4 ICIC66666/7
7.ICICI Bank will process your re#uest. 9estern :nion Business .olutions will then deli(er the C+D payment to
your school to complete the payment.
The followin! quote is valid until4
You cannot use this sheet after this date. If the date above has passed, go online again and create a new quote. Note that there will be a
small processing fee charged by ICICI Bank.
14 April 2014 04:46 GMT.
A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION
For Official Use only
Track Number Originating Br. ID Scan Br. ID AD C!e
"T be cm#$ete! b% t&e a##$icant in b$ck $etter' u'ing b$ack ink #en(
A##$icatin )r !ra*a$ ) +reign E,c&ange
I. Detai$' ) t&e A##$icant "Remitter(
a. Name of the Applicant
b. Address (Not mandatory
for ICICI A/c holders)
Applicant Phone numbers
II. Detai$' ) +reign E,c&ange re-uire! "+i$$.u# eit&er II a r II b( "Re) Anne,.II in #age / )r
a##$icab$e Currenc% Detai$'(
II a. +r remittance ) )i,e! amunt ) +reign Currenc%
Forein Currency
FC
Amount In
!ords
FC Amt in fiures
"OR( II b. +r remittance ) e-ui0a$ent ) +reign Currenc% ) +i,e! Ru#ee Amunt
Forein Currency CA"
IN#
Amount In
!ords
IN# Amt in fiures
II c. Pur#'e ) Remittance *it& Pur#'e C!e "+r !etai$' re)er Anne,ure 1 I in #age 2(
Code
$%%&'
"escription
(ducation
III. I 3 We aut&ri4e %u t !ebit m% 3 ur be$* Accunt tget&er *it& %ur c&arge'
5 C&arge'
brne b%
bene)iciar%
"BEN(
5 C&arge'
brne b%
remitter
"REM(
6
) Chares *ill be to the Account of +eneficiary (+(N) if no option is selected
III a. P$ea'e i''ue
,eleraphic ,ransfer (,,) - "r( "emand "raft ("")
Bene)iciar% Name
, # A . ( / ( - 0 / O + A /
+ U $ I N ( $ $ P A 1 2 ( N , $
Bene)iciar% A!!re''
% % 3 4 % 3 , 5 $ , # ( ( , N ! ' , 5 F / O O #
! A $ 5 I N 0 , O N " C 4 & & & 3
I7 a. Bene)iciar% A3c Number "Inca'e ) TT(
& & & & % % 6 7 % 6
8 %
INR 5,739.08
A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION
I7 b. Name ) t&e Bank *&ere t&e bene)iciar% A3c i' maintaine! "In ca'e ) TT(
# O 1 A / + A N 9 O F C A N A " A
I7 c. SWI+T 8 SORT C!e !etai$' ) bene)iciar% Bank "In ca'e ) TT(
I+AN for remittance made to
U9: (urope: +ahrain $audi
Arabia ; UA(
$ort Code for remittance to
U9 (or) +$+ Code for
remittance to Australia
$!IF, code (or) routin Number for
remittance to any other Country
#O1CCA,4
A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION
I7 !. Bene)iciar% Bank a!!re'' inc$u!ing Cuntr% at *&ic& t&e bene)iciar% maintain' A3c " man!atr%
in ca'e ) TT in CAD Currenc%(
% < & ! ( / / I N 0 , O N $ , # ( ( ,
, O # O N , O O N , A # I O 2 3 % % = %

I7 e. +urni'& t&e )$$*ing !etai$' ) Crre'#n!ent Bank i) t&e +reign Currenc% i' 'ent t a
Cuntr% t&er t&an t&e &me Cuntr% ) t&e Currenc%
SWI+T C!e Crre'#n!ent Bank Name
7. I) t&e #ur#'e 'e$ecte! i' ne ) t&e be$* t&en it i' man!atr% t )urni'& t&e !etai$' 'ug&t )r
Maintenance
,he relationship of beneficiary *ith the remitter (for list of close relati>es refer the table i>en
belo*)
E!ucatin ,he $tudent Name and $tudent I" (if any). Country of study abroad
Purc&a'e )
Pr#ert%
,he location of property bein purchased (Country / $tate)
In0e'tment abra!
Nature of instrument ((?uity / 2F / "ebt Instrument) and country of incorporation of the
company in *hich the in>estment is made
"etails
Li't ) c$'e re$ati0e' a' #er Sec 7I ) Cm#anie' Act
+rother (includin step +rother) "auhter@s $on@s !ife 2other (includin $tep 2other) $on@s "auhter
+rother@s *ife "auhter@s 5usband 2other@s Father $on@s "auhter@s 5usband
"auhter (Includin $tep "auhter) Father 2other@s 2other $on@s $on
"auhter@s "auhter Father@s Father $ister (Includin $tep $ister) $on@s $on@s *ife
"auhter@s "auhter@s 5usband Father@s 2other $ister@s 5usband $on@s *ife
"auhter@s $on 2ember of 5UF $on (Includin step $on) 5usband (or) !ife
7I. +urni'& be$* i) a me''age t be 'ent a$ng *it& *ire tran')er n %ur be&a$)

INR
Dec$aratin
I / !e hereby declare that the total amount of forein eAchane purchased from or remitted throuh all sources in India durin this
Calendar / Financial year includin this application is *ithin U$" /imit as prescribed by #+I for the said purpose under F(2A %777
CA53210KOOU1940
A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION
I/ !e hereby declare that the transaction mentioned abo>e doesn@t in>ol>e: and is not desined for any purpose for *hich the dra*in of
forein eAchane is prohibited under rule B of the F(2A Current A/c transactions #ules: 4&&& read *ith schedule I therefore of .iC:
%. ,ra>el to Nepal ; or +hutan
4. ,ransaction *ith a person resident in Nepal or +hutan
B. #emittance out of lottery *innins
8. #emittance of Income from #acin / ridin etc. or any other hobby.
3. #emittance for purchases of /ottery ticDets: banned or prescribed maaCines: football pools: s*eep staDes: schemes in>ol>in money
circulations: securin priCe money a*ards etc.
6. Payment of commission on eAports made to*ards e?uity in>estments in Eoint >entures / *holly o*ned subsidiaries abroad of Indian
Companies
'. #emittance of di>idend by any company to *hich the re?uirement of di>idend balancin is applicable.
<. Payment of commission on eAport under rupee state credit route eAcept commission up to %&F in in>oice >alue of eAports of ,ea ;
,obacco.
7. Payment related to GCall bacD ser>icesH or telephones.
%&. #emittance of interest income on funds held in nonIresident special rupee a/c schemes.
I / !e: bein a person(s) resident in India: hereby declare that for transactions done under the /iberaliCed #emittance $cheme (/#$) for
resident indi>iduals: issued and amended by #+I from time to time: is not in the nature of remittance for marin calls to o>erseas eAchanes
/ o>erseas counter parties under this scheme.
I / !e: bein a person(s) resident outside India: here by declare that under $ec 8(b) of F(2A Permissible Capital A/c ,ransaction
reulation: 4&&&: the transaction mentioned abo>e doesn@t in>ol>e and is not desined for any repatriation outside India out of the proceeds
of any in>estment in India: in any form: in any Company: Partnership firm (or) Proprietary concern or any entity: *hether incorporated or not:
*hich is enaed or proposes to enae
a. In the business of chit funds or
b. As Nidhi company or
c.In aricultural or plantation acti>ity: or
d. In real estate business: or construction of farm houses (real estate business shall not include de>elopment of to*nships construction of
residential / commercial premises roads or brides): or
e.In tradin and transferable de>elopment rihts (,"#s)
I / !e bein a person(s) resident outside India: here by declare that no portion / part of out*ard remittance represents interest on refunds of
funds recei>ed from outside India for purchase of shares in India. Updated list of prohibited transactions under F(2A can be accessed on
ICICI +anD *ebsite (***.icicibanD.com).
Ot&er re$e0ant !ec$aratin'9
I/*e hereby declare that the purpose and transaction details as mentioned abo>e are true to the best of my Dno*lede does not in>ol>e:
and is not desined for the purpose of any contra>ention or e>asion of the pro>isions of the F(2A: %777 or any rule: reulation: notification:
direction or order made there under. I/!e aree that I/!e shall be responsible and liable for any incorrect detail pro>ided by me/us.
I/!e also hereby aree and undertaDe to i>e such information / documents as *ill reasonably satisfy you about this transaction in terms of
the abo>e declaration.
I/*e aree that in the e>ent of transaction could not be eAecuted/debited to my/ our account after submittin the re?uest for processin to
the banD on account of insufficient/ unclear balance at the same time of eAecution of the transaction in my/ our account any eAchane
losses incurred in this connection due to re>ersal of the ForeA deal can be chared to my/our ICICI account.
I/*e aree that in the e>ent the transaction is cancelled or re>oDed by me/us after submittin the re?uest for processin to the banD any
eAchane losses incurred in this connection can be chared to my/our ICICI account. I/*e further aree that once the funds remitted by
me/us ha>e been transmitted by ICICI banD to the correspondent and/or beneficiary banDs: ICICI banD shall not be responsible for any
delays I the disbursement of such funds includin the *ithholdin of such funds by the correspondent and/or beneficiary banDs. I/!e further
aree that once the funds remitted by me / us ha>e been transmitted by ICICI +anD: intermediary +anD chares may be le>ied by
Correspondent and / or +eneficiary +anDs: *hich may >ary from banD to banD.
I/*e aree that in the e>ent the transaction bein reEected by the beneficiary banD because of incorrect information submitted by me: any
chares le>ied by the beneficiary banD or eAchane losses incurred in this connection can be chared to my ICICI banD account.
I/*e also understand that if I/*e refuse to comply *ith any such re?uirement or maDe only unsatisfactory compliance there*ith: the banD
shall refuse in *ritin to undertaDe the transaction and shall: if it has reason to belie>e that any contra>ention/e>asion in contemplated by
me/us: report that matter to the #+I.
I/*e also aree that the eAchane rate *ill be applicable at the time of deal booDin and may >ary from the rate pre>ailin *hen the re?uest
is submitted . I/*e also understand that the rate communicated to us (if any) is an indicati>e rate and the actual rate may be different from
the same.
I / !e authoriCe you to remit out*ardly as per details pro>ided in the application.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
"ate JJJJJJJJ. Signature ) Remitter 3 Man!ate
:$!er
(,he sinature by mandate holder *ill be accepted only for Non resident A/c holders *here mandate is duly reistered *ith the +anD )
I certify that I ha>e >erified the Customer@s sinature as per +anD records and retained the oriinals of all the scanned
documents and forms submitted by the remitter for the abo>e transaction.
Name ; employee I" +anD $tamp ; (mployee $inature
A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION
(For Office Use Only)
Anne,ure.III
91C Certification
"T be )i$$e! an! 'canne! n$% in ca'e ) remittance b% nn ICICI Cu'tmer(
I met 2r./2s./2rs. KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK at his / her residence / office / other location (specify)
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK and hereby confirm the identity and address i>en belo*
;. Remitter Name
2. Remitter A!!re''

I confirm ha>in >erified the copies of documents (as applicable) *ith the oriinals produced by the applicant.
Also I confirm that the applicant has sined the documents in my presence. /ist of 91C documents pro>ided.
I" Proof
Address Proof
Name of the +anD official KKKKKKKKKKKKKKKKKKKKKKKKKKK (mployee No. KKKKKKKKKKKK "esination
KKKKKKKKKK
"ate L KKKKKKKKKKKKKKK $inature of the +ranch Official and +ranch stamp
Name of +2 / +O2 authoriCin 91C certification abo>e KKKKKKKKKKKKKKKKKKKKKK (mployee No.
KKKKKKKKKK
"ate L KKKKKKKKKKKKKK $inature of the +ranch Official and +ranch stamp
"etails of IN# amount credited to the pool a/c (Incl. of Chares M $er>ice ,aA) KKKKKKKKKKKKKKKKKKKKKKK
Finacle ,ran I". KKKKKKKKKKKKKKKKK I+# No. KKKKKKKKKKKKKKKKKKKKK "ate of credit
KKKKKKKKKKKKKKKKKKKKKK into Pool A/c No.&&B3$/O#C+PC (incase of any other a/c specify)
KKKKKKKKKKKKKKKKKKKKKKKKKKK
(If the remittance is by *ay of acceptin cash deposit then the amount should not eAceed IN# 3&:&&&/I)