|
NEWYORK
BRANCH
ADDITIONAL
INFORMATION FOR REMITTANCES OF USD 3000 OR
MORE
(EQUIVALENT OTHER CURRENCIES) AS REQUIRED UNDER
BANKER'S
SECRECY ACT REGULATIONS
|
(1)
Name:
|
(First
name)
|
(Middle
name)
|
(Last
name)
|
|
| (2)
Address |
Street
Apt # |
| City
State
Zip |
| Phone
(work)
Residence |
| (3)
Social Security number |
a.
Bank account no. |
| b.
Bank and Branch |
| (4)
Details of identification (one of the two) |
PLEASE
ATTACH A PHOTOCOPY |
|
Driving
License
|
Passport
|
(a)
Number
(b)
Date of issue
(c)
Date of expiry
(d)
Place of issue
(e)
Issuing Authority |
:
:
:
:
: |
:
:
:
:
: |
|
| (5)
Details of Beneficiary |
Name
:
|
(First
name)
|
(Middle
name)
|
(Last
name)
|
| Address |
Street |
Apt
# |
| City
/ Town |
State |
Zip |
|
| Bank
account no. |
Bank
Branch |
.
.
SIGNATURE
OF THE APPLICANT
Instructions
received for remittances equivalent USD 3000 or more without the above
form duly filled in and signed will NOT be accepted and the amount
will be returned back after deducting our charges for the return of
the payment |
