Salaried Self-Employed Unemployed Student Housewife

#

Date of Travel* Date of Return*:

Country of Travel*

Purpose of Travel*

1.______________________ 2.______________________ 3.______________________

Business Medical Holiday / Leisure

FCY Amount (in words)

*End use of funds (If amount is more than USD 5,000 equivalent) _________________________________________________________________________

Reason for mismatch in country of travel and currency loaded (only in case there is a mismatch) _________________________________________________________________________

Currency

Forex Card Amt

Forex Card Amt

USD EURGBP SEK CHF JPY HKD NZD

ZARCurrency AUD CAD SGD AED SAR THB DKK

Pilgrimage

Details of Travel*

(*Marked fields are mandatory)

*Mr.

PAN No.*

Customer ID

E-mail ID*

Passport No.*

Your Axis Bank Forex Card Statement will be sent on the above e-mail ID when requested

Mother’s Name* Mrs.

If Axis Bank customer, please provide*

Place of Issue*

First Name* Last Name*Middle Name

First Name* Last Name*Middle Name

Father’s / Spouse Name* Mr. / Mrs.

Date of Birth* Gender* M F Third Gender

Marital Status* Unmarried Married Others

Date of Issue* Expiry Date*

Date

O ce Name & Address*

City*

STD Code* Landline No.* Mobile No.*

Pin Code* State*

Landmark*

City*

STD Code* Landline No.* Mobile No.*

Pin Code* State*

Landmark

Mrs. Ms. Dr.

Customer Details*

Resident

Resident Non-Resident

NRI PIO / OCI

Nationality*_______________________________________

Form version - March 2021

If Salaried* - Public Ltd. Proprietorship Partnership firm Public Sector GovernmentPvt. Ltd.

If Self Employed provide Nature of Business* - Bullion / Gold Jewellery

Trader Money Lender

Annual Income (Salary or business)

Number of Years in Business *

Trust/Association/Society/Club

If Salaried provide - Employer Name* ___________________________________ Job Role* ___________________________________ _______________________________

1

Details of Foreign Exchange required:

(only numeric and absolute value to be filled here,No decimal or negative value allowed)

2

Payment Mode* (Mandatory for New to Bank (NTB) customer)

Other Bank Account

Axis Bank Account Cheque / DD number

Cheque / DD Transfer from own Axis Bank Account Transfer from Own Other Bank Account

Other Bank Name

Investment Income Others

Source of Fund*

Salary

(c) the one is related to the other in the manner indicated above:

Business Income Agriculture

Self Father (including Stepfather) Mother (including Stepmother) Son (including Stepson) Spouse

Son's Wife Daughter Daughter's Husband Brother (including Stepbrother) Sister (including Stepsister)

Signature of the Account Holder

Debit Authority (For Axis Bank Accountholder)

I / We authorize you to debit my / our account number ___________________________________________________ and e ect the Forex Card funding, as detailed above, along with

your applicable charges i.e. Foreign Conversion Tax, Commission & Service Tax.

Country of BirthCity of Birth

Country# 1, please specify)

Details under FATCA and CRS

(Please consult your professional Tax Advisor for further guidance on your tax residency, if required)

______________

___________________

I am a tax resident of India and not resident of any other country

Place: ______________________________________________________________

on this form is

true, correct and complete and hereby accept the same.

th August, 2015 Rules 114F to 114H, as part of the Income Tax Rules, 1962, which Rules require Indian

equivalent of the country in which you are tax resident

form.

#

1

Signature Date:

Air Ticket / Visa Passport Copy PAN

Choose your Card:

b. Axis Bank Club Vistara Forex Card # c. Miles & More Axis Bank World Traveller Card

Documents / Details Provided*

Choose your Forex Card*

Customer Photo

#Axis Bank Club Vistara Forex Card cannot be issued to a minor

Tax Residency City Tax Residency Country

Tax Residency Address

I / We __________________________________________________________ (Name) hereby declare that:-

I / We hereby declare that –

there under.2.

3.

1.

5. overseas counterparty are not allowed under the Scheme.

2.

2. I / We shall be responsible and liable for any incorrect detail provided by me / us.3.

5. advised separately by the RBI to the Banks.

Date

Whether under LRS (Yes / No) Purpose Code

As per the Annex

Sr. No.

Sr. No.

Amount

____ - March ____ )

Name and Address of AD branch /

I wish to purchase a _________ denominated Forex Card for my ward, _____________________________________________ <name of the minor>. I declare that the funds being given

for the purchase of the Foreign Currency to be loaded on the card are being provided by me.

I hereby declare that the date of birth of the minor who is my ____________________ is ____ / _____ / ________ (dd/mm/yyyy) and I am his / her natural and lawful guardian

appointed by Court Order dt. ____________________________________________ (Copy enclosed). I state and confirm that the Forex Card is purchased for the actual use by the

Forex Card. Yours faithfully,

*Axis Bank Club Vistara Forex Card cannot be issued to a minor

First Name Last NameMiddle Name

In case the applicant / nominee is a Minor#

Type of Guardian Father Mother Court Appointed

Full Name of Guardian Mr. / Mrs. / Ms.

Phone No. of the Guardian (in case applicable)

Signature Guardian

(Signature of Guardian)

Address of the Guardian ________________________________________________________________________________________________________________________________ _

Document proof of Guardian _______________________________________________________________________________________________________________________________ _

I hereby declare that the currency being loaded on this Forex Card does not exceed the LRS limit of my individual capacity

and my sole proprietorship capacity combined together for this financial year.

Signature applicant

(Signature of applicant)

Name of the applicant _________________________________________________________________________________________________________

3

SignatureDate Place

securing prize money / awards, etc. d. Payment of commission on exports made towards equity investment in Joint Ventures / Wholly Owned Subsidiaries abroad of Indian Companies

f. Payment of commission on exports under the Rupee State Credit Route, except commission up to 10% of invoice value of exports of tea and tobacco g. Payment related to “Callback Services” of telephones

i . Travel to Nepal and / or Bhutan

on regulatory and internal guidelines.

/ our Axis Bank account.

10. I / We undertake that I / We will not remit payments directly / indirectly outside India in any form towards overseas Foreign Exchange trading through

or recovered directly from the Cardholder and/ or from any accounts (including joint accounts) maintained by the Cardholder with Axis Bank or its group companie s. a). If aggregate foreign currency purchases in any form during the financial year exceeds INR 7 Lakhs and where the foreign currency purchase was made under LRS by the

Cardholder, Cardholder shall bear the applicable Tax Collected At Source (TCS) at the rate of 5% under applicable laws on the amount exceeding INR 7 Lakhs

in such a case Cardholder shall bear the applicable TCS at the rate of 0.5% under applicable laws on the amount exceeding INR 7 Lakhs For the sake of clarity,

15. I / We hereby confirm that my personal / KYC details may be shared with Central KYC Registry.

for any losses or damages caused to the Bank. I also understand that a Service Tax is applicable on all fees, interest and other charges as per the Government of

acknowledge that Axis Bank will act on requests made by any person(s) other than me, claiming to represent me for reload of the Axis Bank Forex Card issued to me. In such an event I shall not contest the said reloading. I, hereby request and authorize agree and acknowledge that, Axis Bank to act and rely on any

visible, readable and as such I hereby agree and confirm that Axis Bank shall not be held liable for and shall be indemnified from, any losses or damages including

any breach of the limits as prescribed under FEMA, and as applicable to me, or if there is any discrepancy / breach of the KYC requirements, and I shall not hold

of Club Vistara Forex, I agree that my personal data may be shared with Club Vistara. Also, in case of any queries pertaining to accrual / usage of Club Vistarapoints shall be directly taken up by me with Club Vistara customer care.

4

Place: ______________________________________________________________Signature of the Card holder

If nominee is Minor, Date of Birth

to receive the amount of deposit on behalf of the nominee in the event of my / our / Minor's death during the minority of the nominee.

Signature of Witness*** _______________________________________________________________ _____________________

Name _________________________________________________________________________________________________________

Address _______________________________________________________________ _______________________________________

Date_________________________ , Place _______________________________

Signature of Primary Applicant** _______________________________________________________________________________

Name ______________________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________

Signature of the Joint Applicant(s) _____________________________________________________________________________

*Strike out if nominee is not a Minor.

I / We (Name) __________________________________________________________________________________ (Address) _________________________________________________________________________________

Nominate the following person to whom in the event of my / our / minor's death the amount of deposit in the above account may be returned by Axis Bank Ltd.

*

I wish to nominate

Name

*As nominee is Minor, I / We appoint (Name

Address Same as Primary Applicant If di erent

Age Years

If di erent from Primary Applicant

Address Same as Primary Applicant

I do not wish to nominate

To earn award miles with your Miles & More Forex Card you have to be a member of the Miles & More program Yes, I am a Miles & More member. My Miles & More Service Card Number is (15 digits)*

t

Miles & More would like to keep you informed about relevant topics

(e.g. by the use of cookies, web beacons, program data and booking data).

[www.miles-and-more.com/privacy-statement].

Market research – Your opinions about Miles & More and your interests in earning and redeeming miles

my mileage balance myself (including early reminders about mileage expiry) in my customer profile on www.miles-and-more.com.

Miles & More Pogram (Only in case of Miles & More Axis Bank World Traveller Card)*

5

Payment Purpose

Purpose Code

S0301

S0303

S0304

S0305

S0306

S1307

Travel for pilgrimage

Travel for medical treatment

S0014

Axis Bank Club Vistara Forex Card (Only in Axis Bank Club Vistara Forex Card)*

To earn Club Vistara Points with your Axis Bank Club Vistara Forex Card you have to be a member of the Club Vistara Program.

Please enroll me for Club Vistara Membership. The membership will be issued in your name subject to Club Vistara T&Cs; plea se visit www.airvistara.com for details.

Name _______________________________________________________________ _ ____________________________________________________________________

Place ______________________________ Stamp __________________________________ Signature & SSN _______________________________ Date ________________________________

All packed for your trip' here's what you need…

How woul

We, at Axis Bank, understand how important and memorable each moment of your trip abroad is, and present you with the Axis Bank Forex Card -a hassle-free, secure and convenient way to carry money and make payments when you travel abroad.

Power packed Card

• A VISA / MasterCard / Discover prepaid Foreign currency Card

• Reloadable via. Internet Banking & Axis Mobile App

• Earn award miles that can be redeemed across more than 350 local & global Miles & More partner (Only for Miles & More Axis Bank World Traveller Card)

• Get free enrol

• With Axis Bank Club Vistara Forex Card get Complimentary Base Tier membership of India's Fastest Rewarding Flyer Program - Club Vistara. Earn Club Vistara points Points that you can redeem for Award flights and upgrade Awards

Axis Bank Forex Card

and us dated __________ .

2. We confirm and declare that the facts stated above are true and correct and that we are aware that Axis Bank has solely relied on the above

the veracity of the statements as above and Axis Bank shall not be held liable for any discrepancies or erroneous statements as contained herein

by us or by the Applicant.

Referral Agent’s Use Only

Agent Name Referral Code Signature & Stamp

SignatureDate Place

For Branch use only

Forex Card*

Account Reference*

Name of issuing Authority Employee ID

Branch Name Branch Code

Stamp and Seal

Field marked* (star) are mandatory.

6

Convenience Guaranteed

• Accepted at over 80 million MasterCard / Visa / Discover Merchant Outlets across the world

• With the Contactless technology of Paywave make your payments faster

Assistance just a call away

• For an

within 2 working days

• As a C ardholder you can also access VISA's Global Customer Assistance Service / MasterCard Global Service, which can be used to report a lost or stolen Card, get emergency cash assistance, and make inquiries (charges applicable)

• Toll-Free numbers available for following countries - India +91 40 6717 4100 (Paid Number), USA 1855 205 5577, UAE 8000 3570 3218, Bahrain 800 11 300, UK 0808 1785 040, Saudi Arabia 800 850 0000, Qatar 00800 100 348, Australia 1800 153 861, Canada 1855 436 0726, Singapore 800 120 6355

Insurance• Lost Card

When you return from your trip, you can choose to:-

1. Get your balance on the Card encashed.

2. Or simso that you can use it for any future trips.

Dynamic currency conversion

are levied by the acquiring Bank the bank that runs the ATM / POS machine.

feature may appear with di ering terminology, depending on the overseas Bank.Axis Bank is not responsible for any 'Dynamic Currency Conversion' related charges, and will not be able to refund any such charges, in case they are levied on account of wrong usage of Card.

UnitedStatesDollar

EUROPoundSterling

AustralianDollar

CanadianDollar

SwissFranc

Rs. 100.00 + GST

Rs. 100.00 + GST

Rs. 100.00 + GST

ATM Charges +

Miscellaneous Requests +

Nil

Nil

ZAR28.13

HKD16.88

NZD3.66

THB90

SAR8.16

AED8.16

SEK16.88

SGD3.66

JPY281.25

CHF2.81

CAD2.81

AUD281.25

DKK15.75

JapaneseYen

SingaporeDollar

SwedishKrona /Kronor

UnitedArabEmiratesDirham

SaudiRiyal

ThaiBaht

NewZealandDollar

HongKongDollar

SouthAfricanRand

DanishKrone

Reload / Renewed Card Fee

Add-on Card Fee

Encashment Charges

PIN Change

Balance Inquiry

Cash Withdrawal

Balance Inquiry (in Abroad ATMs)

Replacement Card Fee

Replacement Card Fee

Date Place

USD EURGBP

AUD CAD

CHF JPY

SGD

SEK

AED SAR THB

HKD NZD ZAR

DKK

Others _____________________

Card Fee Service Tax on conversion

Amount in INR Amount in FCY

Fees & Charges are subject to change. For updated details, please visit www.axisbank.com*Exclusive of Postage and Handling

$

$ ZAR6

HKD4

NZD1

THB25

SAR1.75

AED1.75

SEK3.5

SGD0.95

JPY65

CHF0.7

CAD0.65

AUD0.650.50.50.5

1.411.692.25

$233

$101515

DKK4

ZAR45

HKD25

NZD5

THB150.00

SAR11

AED11

SEK21

SGD4.75

JPY350

CHF3.75CHF

15

CAD5

AUD5

DKK20

ZAR220

HKD120

NZD24

THB550

SAR60

AED60

SEK150

SGD24

JPY2000

CAD20

AUD20

DKK100

Currency Conversion +

3.50%

$1.52.53

$222

$3.253.755

New ATM Pin

New iConnect Password

Charge Slip Retrieval

Chargeback Fee

Sale / Reload and Refund

Usage (Cross Currency)

*Will be levied from 1 st

Nil

Nil

CHF3.75

ZAR35

HKD23.25

NZD4.75

THB100

SAR11

AED11

SEK21

SGD4.75

JPY350

CAD3.5

AUD3.5

DKK21

CHF2.5

ZAR23.5

HKD15.5

NZD3.25

THB80

SAR7.25

AED7.25

SEK15

SGD3.25

JPY250

CAD2.5

AUD2.5

DKK14

CHF6.25

ZAR58.75

HKD38.75

NZD8.25

THB200

SAR18.25

AED18.25

SEK37.5

SGD8.25

JPY625

CAD6.25

AUD6.25

DKK35

As per Bank's Card Rate

7