Spi Funds Transfer Request Form

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 PLEASE CAREFULLY FILL THE APPROPRIATE INFORMATION IN THE SPACE PROVIDE BELOW USED CAPITAL LETTERS ONLY IN THIS FORM. PARTICULARS OF LAWFUL BENEFICIARY:

1.

Full Names of Beneficiary: Contact Address: Contact Phone & Fax: PARTICULARS OF BENEFICIARY’S RECEIVING BANK:

2.

Name of Bank: Address: A/C Number: A/C Name: Swift/Routing Number: FUNDS TRANSFER:

3.

Int’l Transfer Amount:

USD/EURO/POUNDS STERLING

Amount in Words:

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: