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(To Print this form, simply click PRINT of your browser)
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Date: ___________
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Door to Door [ ]
Bank Deposit [ ]
Pick UP [ ] SM Counter
[
] Banco de Oro |
Service
Charge $_______ |
Total
Amount $_______ |
SENDER INFORMATION
Name:
______________________________________________
Address: ______________________________________________
City: ___________________________
State: ___________________________
Zip Code: __________________________
BENEFICIARY INFORMATION
Name:
______________________________________________
Address: ______________________________________________
Town/City: ______________________________
Province/State: _____________________________
Zip Code: __________________
Country: _________________________________
Phone Number: _______________
Bank Name: __________________________________________
Bank Address: _________________________________________
_________________________________________
_________________________________________
Bank Account Number: __________________________
Message for Beneficiary:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Please call Edgar as soon as you submitted this form at
414-352-8230,
especially IF AMOUNT IS $1,000 OR ABOVE. |
