Application Form For Funds Transfer/Bank Draft: Beneficiary Details

APPLICATION FORM FOR FUNDS TRANSFER/BANK DRAFT
For office use:

Date: 08/08/2022
Finacle Customer CIF:
Customer Ref. No.:
Exchange rate:
Please fill in using BLOCK LETTERS and () wherever applicable
Remarks:
Full name of applicant: ACIMMO Reference No:
Contact tel no: +261320536803 e-mail: mrasolondraine@funreco.mg
Please effect the following transaction (tick appropriate box)
✔ Swift Transfer Bank Draft
I/We authorise you to debit my/our Account Number 50100000369529
with transfer amount and charges/commision (as per published table of charges) and remit as below
Transfer Currency US DOLLARS
Foreign Currency amount (in figures) 9,600.00 US$
Currency, and amount (in words) NINE THAUSAND SIX HUNDRED US DOLLARS
Charges: BEN (all local and overseas charges to be borne by beneficiary)
OUR (all local and overseas charges to be borne by applicant)

✔ When customer opts for ‘OUR’ charge option, the Bank does not guarantee full amount credit to beneficiary as same may depend on intermediary/
final beneficiary banks internal policy/arrangement
SHA (local bank charges to be borne by applicant and Foreign Bank charges to be borne by Beneficiary)
Beneficiary Details
FR76 1695 8000 0181 3566 5918 386

Beneficiary Account/IBAN: …………………………………………………………………………………………………………………
For payment in Euroland, Dubai and Switzerland - IBAN no / UK: IBAN No & Sort code / Australia: BSB code / South Africa: Branch code
SOUTHERN CAPITAL INVESTMENT FOR AFRICA (SOCIA) Sasu
Beneficiary Name: …………………………………………………………………………………………………………………………
3, RUE CARNOT 93400 SAINT-OUEN FRANCE
Full Address of Beneficiary: …………………………………………………………………………………………………………………
QONTO BANK
Beneficiary Bank Name: …………………………………………………………………………………………………………………
20 BIS RUE LAFAYETTE , 75009 PARIS FRANCE
Beneficiary Bank Address: …………………………………………………………………………………………………………………
QNTOFRP1XXX
Beneficiary’s Bank Swift Code: ………………………… 16958
Beneficiary’s Bank Sort Code/Branch Code: …………………………………
BNPAFRPP
Beneficiary’s Bank Correspondent Bank and SWIFT code: …………………………………………………………………………………
For remittances in INR currency:

1. IFSC Code: ………………………………………………………………………………………………………………………………
2. Telephone Number of Beneficiary (if available) : ………………………………………………………………………………………
3. Beneficiary’s a/c a Non Resident External Rupee (NRE) account? Yes ✔ No

CONSULTATION POUR OUVERTURE DE COMPTE ET DUE DILLIGENCE
Purpose of payment / remittance (give full details): ………………………………………………………………………………
Student name and ID in case of payment to university: ………………………………………………………… (Please include invoices)
*Invoice to be stamped and signed by applicant

I/WE authorize the bank to effect the above transaction for the lawful purpose given and agree to abide by the terms and conditions. (see next page)
Authorised signatures
(Seal in case of company)
Terms and Conditions
• I /We understand that payment by SWIFT transfer will be entirely at my/our risk and my/our responsibility and on the distinct
understanding that no liability whatsoever is to be attached to the SBM Bank (Mauritius) Ltd (the "Bank") for any loss, arising or resulting
from delay in transmission, delivery or non-delivery of the SWIFT message or for any mistake, omission or error in the transmission or
delivery thereof or in deciphering the message from whatsoever cause or from its mispresentation when received.
• I /We the above named applicant hereby declare that I/we as well as the beneficiary are not involved in or in relation to any act or
dealing with the trafficking of narcotics/dangerous drugs and proceeds of such trafficking, contrary to the Dangerous Drug Act 2000,
terrorist financing under the Prevention of Terrorism Act 2002, and/or such money laundering offences under the Financial Intelligence
and Anti-Money Laundering Act 2002 and any other international applicable legislation.
• It is understood that the above instructions are subject to there being no legal restrictions including but not limited to Anti-Money
Laundering/Counter-Financing of Terrorism legislations, regulations and conventions preventing SBM Bank (Mauritius) Ltd from
processing this transaction. In case funds are blocked by/with any authorities for any such reasons, this will be entirely on applicant’s
liability and risk without any recourse to the Bank.
• In the event that the funds have been returned unpaid for whatever reasons or funds have been recalled on your instruction, funds net
of any commission will be credited back to your account at the prevailing buying TT rate. In case the returned funds have to be remitted
again with new/additional details, such remittance shall be treated as a new one with all applicable commission and charges.
• Application of the Remittance may be subject to any exchange control regulations or restrictions in the country where account is to be
credited. Neither the bank nor its correspondents shall be liable for any loss or delay caused due to any such rules and regulations.
• The SBM Bank (Mauritius) Ltd shall not be responsible for delay of postal delivery of debit advices.
• Applications will in general be processed for spot value. Rates may vary at the discretion of the Bank and may change without any prior
notice. Any transfer for the same day value will be subject to cut-off time related to the geographical location of the destination, quantum
and prior arrangement with Treasury. The SBM Bank (Mauritius) Ltd (the "Bank") shall not be liable for any delay due to incomplete
information and may impose additional charges for failure to quote the valid Bank/branch clearing code / Swift address. Any charges levied
by the Foreign banks will be passed on to the applicant.
• The application and these conditions shall be governed by and construed in accordance with Mauritian law.
• Transactions effected after cut off time on any business day or during weekends and public holidays will be processed on the next
business day.
• The Bank reserves its right to postpone any payment based on priority basis and on prevailing market conditions
For office use : - Service Unit
Signature & Details Verified: Yes No Called in Person: Yes No
Request Sent by E Mail If No, Call Back done: Yes No
Disclaimer Held: Yes No

(If Yes, state email address of sender)
Request Sent by E Mail Yes No
Note: Where request has been sent for processing by email, the Original document should be filed at Service Unit to avoid duplication.
Name of Officer: Signature:
Name of Supervisor: Signature:
Date: Seal of Unit:

Application Form For Funds Transfer/Bank Draft: Beneficiary Details

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APPLICATION FORM FOR FUNDS TRANSFER/BANK DRAFT

For office use:

Contact tel no: +261320536803 e-mail: mrasolondraine@funreco.mg

Please effect the following transaction (tick appropriate box)

✔ Swift Transfer Bank Draft

I/We authorise you to debit my/our Account Number 50100000369529

Charges: BEN (all local and overseas charges to be borne by beneficiary)

OUR (all local and overseas charges to be borne by applicant)

FR76 1695 8000 0181 3566 5918 386

For remittances in INR currency:

3. Beneficiary’s a/c a Non Resident External Rupee (NRE) account? Yes ✔ No

*Invoice to be stamped and signed by applicant

For office use : - Service Unit

Signature & Details Verified: Yes No Called in Person: Yes No

Request Sent by E Mail If No, Call Back done: Yes No

Disclaimer Held: Yes No

Name of Officer: Signature:

Name of Supervisor: Signature:

Date: Seal of Unit:

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