Webmoney Transfer Verification Application For A Personal Passport

WebMoney Transfer Verification Application for a Personal Passport Last Name: _________________ First Name: ______________ MI.____________ ID Type: ________ Number: ______________ Issued by: ____________________________________________________________________________________ On: __________ (MM/DD/YYYY) Date of Birth: _______________ (MM/DD/YYYY). Place of Birth: _____________________________________ Permanent address: ____________________________________________________________________________ _____________________________________________________________________________________________ (Country, state/province, city/town, zip code, and full street address)

I am requesting the operator of WebMoney Transfer System (WM Transfer Ltd.) to accept my personal data for certification and authorize me as a legal holder of WebMoney Transfer Personal Passport.

My contact information:

Phone: __________________________________________________________________ Fax: ____________________________________________________________________ Email: __________________________________________________________________ WWW: _________________________________________________________________ WM-ID: ________________________________________________________________ Current place of residence (if different from above): ______________________________ (Country, state/province, city/town, zip code and full street address)

I am certifying my interest in acquiring a WebMoney Transfer Personal Passport and am validating this statement with my handwritten signature below:

Signature: _______________________ Date: __/ __/200_

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