AXIS TRAVEL CURRENCY CARD – Refund Form

(To be filled in Capital Letters only)

TRANSACTION DETAILS

Currency Option : USD___ GBP___ EUR___ AUD___ CAD___ JPY___ SEK___ CHF___ SGD___AED____SAR____

Refund Amount: In figures____________ In words____________ ________

Type of Encashment : Partial / Full

Have you settled your Forex with you company : Yes / No If No, Amount due to them :

Card Number    

Account Number 
PLEASE TELL US ABOUT YOUR SELF

Name of the Employee Mr. /Ms________________________ _________________________

Employee Code: ____________ Date of Birth ______________ Mother’s Maiden Name ________________________

Postal Address (Current) ________________________________________ ____________________

_________________________ City __________________________ Pin_____________________

Phone no _________________Mobile __________________ Email____ _____

PLEASE FILL IN THE FOLLOWING INFORMATION

Passport Number ______________________ Place of Issue ________________ ________

Date of Issue ______________________ Expiry Date __________________ ______

Mode of Encashment : Pay order / Direct Account Credit

BANK A/c Number ______________________________________________

A/c Name _______________________________________________

Bank Name _______________________________________________

Branch Details _______________________________________________

IFSC CODE (11 digit) _______________________________________________

(OR) Pay Order Favoring ______________________________________________

I will be bound by the terms and conditions governing the AXIS BankTravel Currency Card, as may be in force from time to time and use of this card
shall be deemed to be acceptance of these terms and conditions. I authorize AXIS Bankand or its associates to verify any information or otherwise at
my office/residence or to contact me, my Employer/ Banker / Credit Bureau/ RBI or any other source to obtain or provide any information that may
be required for confirming membership requirements or maintaining my account in good standing. I agree to an ongoing confirmation for use of my
name/address, email/ mobile nos. for marketing / merchandising offers between AXIS Bankand other companies. I understand and acknowledge that
the local laws and RBI rules and regulations lay down norms and limits for purchase and use of foreign exchange. I agree not to hold Axis Bank
responsible on any delay or invalid credits, I declare that I have not requested for encashment while I am overseas. I undertake that the usage of
AXIS BankTravel currency card by me will be in accordance with the exchange control regulations of RBI and applicable laws in force from time to
time. In particular and without limitation, the FEMA act 1999, in event of failure on my part to do so or in the event of any information supplied by me
being incorrect or inaccurate. I agree that I will be solely liable for any penalties and / or action under the local laws and/or regulations as may be in
force, governing the purchase and use of AXIS BankTravel Currency Card.

Signature of Primary Card Member__________________________________ Date_____________