ForeignExchangeInwardTravel NED ENG.dot 09Jan14 | SD2



Please ([pic]) where applicable.

Note: For Outward BoP category codes contact your nearest branch or access

* Indicates mandatory fields to be completed, including South African Reserve Bank (SARB) requirements.

|PURCHASED FROM | Nedbank client | Non-Nedbank client (FICA documentation required) | Non-resident |

| | Travellers cheques | Foreign bank notes | Travel card |

|ENCASHMENT METHOD* | Cash | Nedbank account | |

|SELLER’S DETAILS |

| Entity |

|Entity name* |      |Trading name |      |

| | | |

|VAT number |      |Registration number* |

| | | | |

| Individual |

|Title: | Mr | Mrs | Miss | Doctor | Prof | Other |      |

|First name* |      |Surname* |      |

|Passport number |      |ID/Temporary-permit number* |      |

|Tax number |      |Country where passport | |

|Gender | Male | Female |was issued |      |

| | | | |

| | |Date of birth |

|Physical address line 1* |      |Postal address line 1* |      |

|Physical address line 2 |      |Postal address line 2 |      |

|Suburb* |      |Suburb* |      |

|City* |      |City* |      |

|Province/State* |      |Province/State* |      |

|Postcode/Zip* |      |Postcode/Zip* |      |

|Country* |      |Country* |      |

|Contact person's first name* |      |Contact person's surname* |      |

|Telephone number* |      |Fax number |      |

|Email address |      |

|ACCOUNTHOLDER’S DETAILS |

| Entity |

|Entity name* |      |Trading name |      |

| | | | |

|Residential status* | Resident | Non-resident |Registration number |

| | | |

|Account number |  |  |  |

| Individual |

|Title: | Mr | Mrs | Miss | Doctor | Prof | Other |      |

|First name* |      |Surname* |      |

|Residential status* | Resident | Non-resident |ID/Temporary-permit number* |      |

|Passport number |      |Country where passport was issued|      |

|Tax number |      | |

| | | | |

|Gender |

|Account number |  |  |

|Physical address line 1* |      |Postal address line 1* |      |

|Physical address line 2 |      |Postal address line 2 |      |

|Suburb* |      |Suburb* |      |

|City* |      |City* |      |

|Province/State* |      |Province/State* |      |

|Postcode/Zip* |      |Postcode/Zip* |      |

|Country* |      |Country* |      |

|THIRD-PARTY’S DETAILS* |

| Did you pay for the forex and did you travel alone? OR | | |

| Did you pay for the forex but did not travel? OR |Number of third parties that travelled |      |(Complete Third-party Travel form) |

| Did you pay for the forex and travel with third parties? |Number of third parties that travelled |      |(Complete Third-party Travel form) |

|CURRENCY ALLOCATION |

|If the travel allowance is redeemed on behalf of other travellers, complete the following: |

| |NAME |AMOUNT |CURRENCY |

|Traveller 1 |      |      |      |

|Traveller 2 |      |      |      |

|Traveller 3 |      |      |      |

|Traveller 4 |      |      |      |

|Traveller 5 |      |      |      |

|Traveller 6 |      |      |      |

|BANKNOTES |

|CURRENCY |AMOUNT |CURRENCY |AMOUNT |CURRENCY |AMOUNT |

|USD |      |JPY |      |THB |      |

|GBP |      |NZD |      |CHF |      |

|EUR |      |MUR |      |HKD |      |

|AUD |      |SEK |      |BWP |      |

|CAD |      |SGD |      |OTHER |      |

|TRAVELLERS CHEQUES: | American Express® | Other |

|TRAVELLERS CHEQUE SERIAL NUMBER |CURRENCY |AMOUNT |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|INDEMNITIES |

NEDBANK e travel allowance is redeemed on behalf of other travellers, complete the following:Any quotation, indication, communication or notification in any form by Nedbank of the exchange rate is merely indicative of the rate at that time, and is subject to change without notice and will not be binding on Nedbank, unless confirmed by Nedbank in writing. Further note that exchange control procedures may cause delays and Nedbank will not be liable for any claims, losses and/or damages due to these delays.

|BALANCE OF PAYMENTS (BOP) REPORTING CATEGORIES – INWARD PAYMENTS* |

|Specify the relevant BoP categories and additional mandatory information, for this transaction: |

|BOP CATEGORY CODE |AMOUNT |CCN |EXPORTER’S REF/UCR |LOAN REF NUMBER |ORIGINAL REF NUMBER |

| | |Mandatory for categories: |Mandatory for categories: |Mandatory for categories: |Mandatory for categories: |

| | |100, 101, 103, 105, 106, |101, 103, 105, 106 |309(4-7), 106, 801, 802, |100, 200, 300, 400, 500, |

| | |109 | |803, 804 |600, 700, 800 |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|NON-RESIDENT EXPORTER’S DETAILS |

| Entity |Entity name |      |

| Individual |First name |      |

| |Surname |      |

|Physical address line 1 |      |Physical address line 2 |      |

|Physical address line 3 |      |Suburb |      |

|City |      |State |      |

|Zipcode |      |Country |      |

|SELLER/ACCOUNTHOLDER’S SIGNATURE* |

I/We do hereby declare that:

• the information furnished above is true and correct in all respects;

• any documentation required in terms of the SARB Rulings and Regulations and presented in support of this transaction is authentic in all

respects;

• the conclusion of this transaction in itself or in conjunction with other transactions of this type will not result in the overall limit imposed in

terms of the SARB Rulings and Regulations, being exceeded;

• I/we am/are aware that the information relating to this transaction will be provided to the SARB, the South African Revenue Service, the

Financial Intelligence Centre and the Financial Services Board; and

• the content hereof is known and understood by me/us.

|Signed at |      |On |      |

| |(Place) | |(Date) |

|Authorised signature | |Authorised signature | |

|For and on behalf of |      |

|(full company name) | |

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