Foreign Money Transfer Request Form page 1

Branch Code Branch Name ⃰ Date (DD/MM/YYYY) ⃰

02930 YELASAWLA 0 3 2 0 1 8

1. ORDERING CUSTOMER DETAILS • Individual or Organization (Must Hold a Permitted CBE Transaction Account).
Full Name ⃰
YERRA SAI SAMPATH
Full Address (Incl. Country P.O. Box) Post Code

DEPARTMENT OF CIVIL ENGINEERING, ARBA MINCH UNIVERSITY (SAWLA CAMPUS), YELASAWLA 13

Optional Passport Number Birth Date Place of Birth

M1109288 22-03-1991 INDIA

2. FUNDING DETAILS
FMT Payment debited from Our Account in CBE currency ⃰
Account Number ⃰ Instructed amount; Foreign Currency Amount ⃰
Or ETB Equivalent Amount ⃰ 1830 USD
1 0 0 0 2 2 2 9 4 6 2 8 3
3. BENEFICIARY DETAILS • Person or organization to be paid overseas
Beneficiary Bank’s Name ⃰
kotak Mahindra Bank
Beneficiary Bank’s Address (full branch address, incl. country)
Machilipatnam, ANDHRA PRADESH, INDIA

If applicable SWIFT/BIC Code (If known) Bank Code (i.e. .IFSC (INDIA) ABA Routing or Fed wire Number (U.S.A.)/ Sort Code (U.K.)/Branch Code)

KKBKINBB KKBK0007850

Beneficiary’s Full Name⃰

YERRA SAI SAMPATH

Beneficiary’s Full Street Address (incl. country and P.O. Box) Beneficiary’s Phone No.

8-22-13/1, JUVVALLAPALEM, TADEPALLIGUDEM INDIA +91 9885453009

Beneficiary’s Account No. or IBAN (IBAN required for payments to Europe and selected other countries) Post Code
6 1 1 1 9 5 2 5 3 5 534102
Purpose of Transfer ⃰

FEBRUARY SALARY TRANSFER

You confirm that the details of charge (all transaction charge to be borne by) ⃰
Beneficiary Customer (BEN) Ordering Customer (OUR) Shared Charge (SHA)

I/We have read, understood, and accept the terms and conditions overleaf
Authorized Signatory Authorized Signatory

4. BANK USE ONLY

Reference number ⃰

Correspondent Bank ⃰

Authorized Signatory Authorized Signatory