Fillable International Money Transfers Remittance Form printable pdf download

Hong Kong Branch

Connaught Road Central Branch

FOR BANK USE ONLY

Unit 1504B-1505, Level 15, International Commerce Centre, 1, Austin Road West, Kowloon, Hong Kong.

INTERNATIONAL MONEY TRANSFERS REMITTANCE FORM

*Mandatory Fields

A. Remitter Details

Mr.

Ms.

Dr.

Other (Please Specify)_____________________________________________________

Full Name*

(First Name)

(Middle Name)

(Last Name)

Address*

City

Postal Code

Phone No.*

Email: ______________________________________________________________________

*Account number with ICICI Bank Limited, Hong Kong Branch

*Customer ID for relationship with ICICI Bank Limited, Hong Kong Branch

B. Beneficiary Details

Mr.

Ms.

Dr.

Other (Please Specify)_____________________________________________________

Full Name*

(First Name)

(Middle Name)

(Last Name)

Communication Address*

City

Postal code*

Phone No.*

Email __________________________________ Nationality

C. Transaction Details

Money Transfer Amount (in words)*__________________________________________________________________________________________

(In figs.)* __________________________ A/c Type (beneficiary)*__________________ Currency of Transfer*____________________________

Purpose of Remittance*

Personal gifts to individuals

ICICI BANK LIMITED, INDIA ACCOUNT

NON ICICI BANK LIMITED, INDIA ACCOUNT

Account Number*

Bank Name*______________________________________________________________

Branch Name _____________________________________

Account Number*_______________________________________________________

City ________________________________________________

Branch Address ____________________________________________________

City* ______________Country*______________Postal code*____________

IFSC code

Disbursement Mode:

Credit to ICICI Bank Limited, India Account (T+1)

Insta credit to ICICI Bank Limited, India Account

Draft to beneficiary

Draft to beneficiary bank

Credit to non ICICI Bank Limited, India Account (NEFT/RTGS)

Payment Mode:

Debit ICICI Hong Kong a/c

*Cheque (fill cheque details below)

For my/our account and risk without any responsibility or liability to yourselves and subject to the terms and conditions mentioned in

the General Terms and Conditions (governing accounts and secured facilities) and Money Transfer Terms and Conditions, which I/we

agree and accept, please effect this transaction as detailed above. I/we agree to bear all the applicable charges for the transaction as

stipulated by ICICI Bank Limited, Hong Kong Branch. l/We further understand that the remittance service offered to me/us by ICICI Bank

limited, Hong Kong Branch is on the basis of the statement/declarations made by me/us.

Cheque details (to be filled by remitter)

Cheque no.

Bank and branch name

Drawer

Date

Amount

Total

Customer

Main Applicant

Co- Applicant 1

Co- Applicant 2

Co- Applicant 3

Date*

Signature

Place*

For ICICI Bank Hong Kong use only.

Remittance Amount *FX rate

Charges Value Date

* Amount to be

Verified by (employee Authorized by (employee

in HKD/USD

received by beneficiary

ID and signature)

For account holders of ICICI Bank Limited, Hong Kong Branch, terms and conditions governing the remittance service as provided and consented to in the General Terms and

Conditions (governing accounts and secured facilities) and Money Transfer Terms and Conditions will be applicable.

Form number

Remittance Amount

*FX rate

Charges

Value Date

Mode of

*Amount to be received

in HKD/USD

disbursement

by beneficiary

*When funds are deposited in the form of a cheque, the exchange rate mentioned herein is an indicative rate.Exchange rates prevailing on the day when clear funds are

received after cheque clearing will be applied for conversion.

Serial No.

Acknowledgement

Branch Stamp & Date

V3.0, effective 17 Mar, 2014.