Travel Card n Multicurrency Application Form

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ICICI Bank Travel Card Application Form
PLEASE FILL THE DETAILS IN BLOCK LETTERS
IF APPLICANT IS MINOR AS ON TRAVELLING DATE
NOMINATION DETAILS
I would like to apply for: ICICI BANK TRAVEL CARD ICICI BANK MULTICURRENCY PLATINUM TRAVEL CARD
First Name* : Mr./Ms.
Parent Name / Guardian Name* :
(All * marked are mandatory field)
Middle Name :
Relationship with Guardian : Son Daughter Others
Last Name* :
Nature of Guardianship : Natural Court Appointed
Date of Birth* : Gender : Male Female
Mother's Maiden Name* :
Company Name :
Choice of Currency* : USD EUR CHF CAD AUD AED JPY SGD GBP
Subscribe to International
One Assist services* : __________________________________________________________________________________________________
Would you like to avail of the free comprehensive Travel Insurance policy from ICICI Lombard? *(Yes / No) ____________________________________________
Passport Details* : Passport Number -
Issued on __________________ at _________________________valid upto _____________________
Purpose of Travel* : Business Leisure Education Employment Medical Cultural tours
Emigration Others
Mailing Address* :
E-mail Address* :
City :
State :
STD Code :
Mobile Number* :
Phone Number of Guardian :
PIN Code :
Phone Number (Res)* :
I am Travelling to* :
Expected date of return to India* :
On
PAN (In case paid by cash
above Rs. 25,000 :
Subscribe to International
One Assist services* : Yes No
(This is a priced service from One Assist towards International Trip assist, for more details please visit the Forex Desk at branch)
I/We ______________________________________ (name( s) & address(es) of the cardholder(s)) nominate the following person (details provided hereunder) to
whom in the event of my death the amount of deposit in the account, particulars whereof are given below, may be returned by ICICI Bank Limited.
Where the card is availed by a minor, the nomination should be signed by a person lawfully entitled to act on behalf of the minor. Nomination can be made in favour
of only one individual.
Nominee's Name :
Relationship with applicant :
Mailing Address :
City :
PIN Code : State :
MANDATORY IN CASE OF NOMINEE IS A MINOR
*As the nominee is a minor on this date, I / We appoint the Guardian (details provided hereunder) to receive the balance amount of the
card on behalf of the nominee in the event of my/our/minor's death during the minority of the nominee.
Date of Birth* :
Guardian's Name :
Relationship with applicant :
Signature of the Applicant
I /we have been explained about the benefits of the nomination facility. However, I / we would like to inform
you that I / we do not wish to provide nomination for this account.
If status of applicant is as a PEP*(Politically Exposed Person): ( Yes / No){strike out which is not applicable}
FORM A2
Application for drawal of foreign exchange
a. Name : Mr./Ms.
Payment Mode : Cash Debit to Bank a/c Cheque/DD EEFC/RFC a/c. Credit Card
b. Address :
c. Account No. :
d. Estimated date of return :
1. Amount (Specify currency) :
2. Purpose
III.
*a) Issue ICICI Bank Travel Card for amount of: ______________________________________________
Application cum Declaration (To be completed by the applicant)
I. Details of the applicant -
II. Details of the foreign exchange required
Declaration
(Under FEMA 1999)
I, _________________________ declare that -
I hereby confirm that the FES transaction as mentioned above is in compliance with the requirements of the circular Ref No. ___________________________
Signature & Account no of the customer is verified by:
*1) The total amount of foreign exchange purchased from or remitted through all sources in India during this calendar year including this application is within


USD_____________(USD__________________________________________________________________only) the annual limit prescribed by
Reserve Bank of India for the said purpose.
*2) Foreign exchange purchased from you is for the purpose indicated above.
(Strike out whichever is not applicable) Signature
Date: Name ______________________
AD Code No. _________________ Issued Card No._____________ Amount Loaded __________________
Form No.____________________ Card Ref No._______________ Amount Received (in INR)___________
FOR OFFICE USE ONLY
City :
State : PIN Code :
(All fields are mandatory)
I authorise you to debit my Saving Bank / Current / RFC / EEFC Account Number __________________________ together with
your charges / I enclose herewith Cheque / Pay Order/ DD No. ______________________ dated _________________________ drawn
on “ICICI BANK LTD.”
for Rs. ___________________________________________________________________________________.
To be completed by aplicant
(To be filled in by Authorized Dealer) All fields are mandatory.
Please ensure you have verified
the application form and
following documents: Copy of Passport Copy of PAN Card / Form 60 VISA
Instasell Maker User ID: Employee No. : ____________________
Employee Name: _______________________________________________________________
Branch Name: Date:
_______________________________________
_______________
______________________________________________
Rubber Stamp of Bank Branch Or Money Changer
(with date)
Ads should put a tick against an appropriate purpose code. (In case of doubt/difficulty, consult customer/RBI.)
The purpose codes for Foreign Exchange Services is listed below:
S0301 Business travel.
S0303 Travel for pilgrimage.
S0304 Travel for medical treatment.
S0305 Travel for education (including fees, hostel expenses.
S0306 Other travel (including holiday trips and payments for settling international credit cards transactions).
(if paid by cash above Rs.25,000)
CUSTOMER DECLARATION
1. I/We hereby declare, confirm, undertake and additionally the guardian hereby declares, confirms, undertakes on behalf of the minor
as follows:

1.1 That as on the date of filling this form, the said applicant is a minor as per applicable laws and the guardian is the natural/court
appointed guardian of the applicant.
1.2 That the guardian undertakes to represent the said minor in all transactions in connection with the ICICI Bank Travel Card (“IBTC”)
issued to the minor pursuant to this form. The guardian also accepts sole responsibility for all acts and / or omissions of the minor
with respect to the issue and usage of the IBTC and undertakes to keep indemnified ICICI Bank against any loss / harm / damage
suffered by ICICI Bank as a result of the same.
1.3 That the information included in the application is true, correct and up to date in all respects and I/we have not withheld any
information.
1.4 I / We shall inform ICICI Bank regarding any change in my/our/minor's residence / employment and shall provide any further
information/ updated KYC documents that ICICI Bank may require from time to time.
1.5 I and the minor are Resident Indians and that I and the minor are eligible to apply for an internationally valid card.
1.6 I / We accept that ICICI Bank is entitled in its absolute discretion to accept or reject this application without assigning any reason
whatsoever.
1.7 I / We agree that it is my / our responsibility to obtain the terms and conditions of the ICICI Bank Travel Card separately and read
them. If this application is accepted, I shall be bound by the terms and conditions as may be in force from time to time and the use
of the card shall be deemed to be an acceptance of those terms and conditions.
1.8 I / we authorize ICICI Bank and/or its associates to verify, make enquiries which ICICI Bank consider necessary in respect of or in
relation to information in this application/further applications.
1.9 I / we agree to an ongoing confirmation for use of my / our name, address, e-mail ID and mobile number for
marketing/merchandising offers between ICICI Bank and other companies. I alsoauthorize ICICI Bank & its group companies to call
me or SMS me with reference to my application, ongoing offers or other products and benefits. This will override registry on the
DNC / NDNC.
1.10 I am traveling abroad for the purpose as indicated in application form. The visa/ tickets for travel to the said countries is in my
possession/ been cleared and is being allotted to me.
1.11 I hereby declare that the aggregate value of foreign exchange purchased by me, including this particular transaction, during the
last 30 days, including the present date, either from ICICI Bank or from any other Authorised Dealer, by making payment in INR
currency notes does not exceed Rs.50,000. I hereby declare that the above details are true and correct and that the total amount of
foreign exchange purchased from or remitted through, all sources in India including this application does not exceed the limit
prescribed by Reserve Bank of India for the purpose indicated above. I undertake that the usage of the same by me will be in
accordance with the extant regulations of RBI and the applicable laws in force from time to time. I state and agree that in the event I
do not travel as aforesaid, I shall surrender the availed foreign exchange to ICICI Bank within 60 days of the release of foreign
exchange to me. I hereby declare that the funds provided by me for purchase of foreign exchange are from legitimate sources and
are not in contravention of any law for the time being in force in India.
1.12 I / we understand and acknowledge that local laws and Reserve Bank of India rules and regulations lay down norms and limits for
the purchase and use of foreign exchange. I undertake that the use of the ICICI Bank Travel Card by me will be in accordance with
the Exchange Control Regulations of the Reserve Bank of India and the applicable laws in force from time to time, in particular and
without limitation, the Foreign Exchange Management Act, 1999. In the event of any failure on my / our part to do so or in the
event of any information supplied by me being incorrect or inaccurate, I / we agree that I / we shall be solely liable for any/all
penalties and/or action under the local laws and/or regulation as may be in force and, governing the purchase and use of the ICICI
Bank Travel Card.
1.13 ICICI Bank reserves the right to retain the application forms and documents provided therewith, including photographs, and will
not return the same to me/us. I / We hereby authorise ICICI Bank to exchange, share or part with all the information/data provided
herein including personal and business information with its Group Companies, financial institutions / credit bureaus / agencies /
Reserve Bank of India or any other regulatory or statutory bodies / other such persons, in order to facilitate ICICI Bank to comply
with its obligations under various applicable laws, regulations, and standards or as shall be required or deemed fit by ICICI Bank. I /
We shall not hold ICICI Bank or its directors/employees/ agents / representatives liable for sharing information provided herein for
the said purpose.
Signature of primary applicant /Parent or Guardian in case of minor

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