1

DATE OF REQUEST

               BRANCH:

2

CURRENCY / AMOUNT

Figures:

Words:

   3

ORDERING CUSTOMER

Account No:

Name:

Full Address:

4

INTERMEDIARY BANK, IF ANY

Name:

Full Address:

SWIFT BIC:

   5

BENEFICIARY BANK DETAILS

Bank’s Name

Bank’s Account No. If Any:

Full Address:

SWIFT BIC (Minimum 8 Characters)

Sort Code (6 Numbers for UK Banks):

Routing Number (9 Numbers US Banks):

Chips UID (6 Numbers):

BL (8 Numbers for German Banks):

6

BENEFICIARY CUSTOMER

Account No:

Name:

Full Address:

7

REMITTANCE INFORMATION

Purpose:

Invoice/Document No.:

8

CORRESPONDENT BANK CHARGES

Shared /with beneficiary / Our (Customer to borne):

9

It is understood that the message will be sent electronically or otherwise at my/our risk in every respect and that neither you nor your correspondents will be liable for the consequences in any delay, mistake or omission in transmission.

10

 Please debit my/our Account No. …………….……………..…with cost and charges thereof.

 (1) Signature………………..    (2) Signature……………   (3) Signature………………..….

                                    DO NOT WRITE BEYOND THIS LINE

11

OFFICIAL USE ONLY

TT REF NO:

AMOUNT:

EXCHANGE RATE:

LEONE EQUIVALENT:

EXCH COMM:

12

APPROVED BY:

A:.........................       B:...........................

SWIFT CHARGES:

TOTAL SLL: