Spi Funds Transfer Request Form 1

FUNDS

(For Use by SPI authorized

personnel Only)

TRANSFER REQUEST Preparer’s Signature Authorized Signature Verifier’s Signature

Credit

Approver’s Name Date and Time of Transaction Section 1. Customer Information (* = Required Field) Customer Information and Identification: As a government regulated futures commission merchant, Interbank Payment Service (SPI), is required to obtain certain customer information to verify your identity in accordance with the anti-money laundering procedures required by the USA Patriots Act and set forth in the regulations promulgated by the National Futures Association. In order to process and approve the transfer of your funds, please provide complete information in response to the following application.

Personal Information * First Name: * Last Name: * Day Phone: Mobile Phone: * Date Of Birth: * No. of Dependants: * Marital Single Married Status: Passport #: Physical Street Address (P.O. Box cannot be accepted) * Address 1: Address 2: * City: * Country: Mailing Address:

* Primary Email: * Re-type Prim. Email: * Evening Phone: Fax: * Gender: Male Female * Country of Citizenship: Soc. Sec. #: Driver's License #:

Apt/Suite: Address 3: * State/Province: * Zip/Postal Code:

Employment Information Employment Status: * Bus. Name: * Bus. Addr. 1:

* Nature of Business: Apt/Suite:

Required for US citizen only.

Address 2: * City: * Country:

Address 3: * State/Province: * Zip/Postal Code:

* Bus. Phone: Bus. Email:

* Your Position: * Years Employed:

Bank Information * Bank Name: * Bank Address 1: * Bank Account#: * Swift/Routing #: * Account Name:

* City: * Zip/Postal Code:

* Country:

* Bank Phone:

* State/Province: * Bank Address 2:

CUSTOMER CONTRACT ALL OF THE ABOVE INFORMATION IS COMPLETE, CORRECT AND PROVIDED TO SPI: INTERBANK PAYMENT SERVICE FOR THE PURPOSE OF INSTRUCTING SPI: INTERBANK PAYMENT SERVICE TO TRANSMIT A FUNDS TRANSFER. SPI: INTERBANK PAYMENT SERVICE ACCEPTANCE AND EXECUTION OF THE FUNDS TRANSFER IS SUBJECT TO THE TERMS AND CONDITIONS OF INTERNATIONAL REMITTANCE. MY SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED A COMPLETED COPY OF THIS FUNDS TRANSFER REQUEST.

Customer Signature:

Date: