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(Incase of a Firm / Company obtain this application on their Letterhead)

The Branch Head

AXIS Bank Ltd.

Mandsaur Branch

Dear Sir,

Sub: Disposal instruction of Foreign Inward Remittance & FIRC application

I/ we request you to credit the Foreign Inward Remittance received favouring me/ us to my/ our EEFC/ RFC/ FCNR(B) Account No._ 910020028215136 _ for International Journal of Advanced Research in Computer Science __ and the balance amount to my/ our INR Account No. __________910020028215136________ after deduction of your charges.





Name and address of Remitter

4026 QUADRA ST APT 407






Canada Trust


Name & address of the Remitting

Branch: 9986









50 USD


Remittance amount in Foreign







Publication fee (For paper ID 3843)


Purpose of remittance






AXIS Bank’s Ref No. & date



Customer Ref. No., if any



FIRC (Please Tick -

A. Required ( v ) B. Not Required ( )

** Please note that FIRC will not be issued to Non Residents.

The declaration-cum-undertaking under Sec 10(5), Chapter III of FEMA, 1999 is enclosed as under:

I/We hereby declare that the transaction details of which are mentioned above does not involve, and is not designed for the purpose of any contravention or evasion of the provisions of the aforesaid Act or of any rule, regulation, notification, direction or order made there under.

I/We also understand that if I/we refuse to comply with any such requirement or make only unsatisfactory compliance therewith, the Bank shall refuse in writing to understand the transaction and shall if it has reason to believe that any contravention / evasion is contemplated by me / us report the matter to RBI.

I/We also hereby agree and undertake to give such information / documents as will reasonably satisfy you about this transaction in terms of the above declaration.

* I/We further declare that the undersigned has the authority to give this application, declaration and undertaking on behalf of the firm/company.

Thanking you,

Yours faithfully,

Date : 04/1/13

Place : Mandsaur (Signature of the applicant)

Name: Babita Bhatt Address: 16, Saket Nagar, Nai Abadi, Mandsaur (M. P.)

I. E . Code :_____________________________

*Applicable when the application /declaration /undertaking is signed on behalf of the firm / company