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This document is a remittance application form requesting a demand draft, bankers check, telegraphic transfer, or SWIFT payment. It requests information such as the applicant/sender name and address, amount in words and figures, value date, intermediary bank details (if any), beneficiary bank SWIFT code and address, beneficiary name and address, purpose of transfer, EBOP purpose code, and mode of payment. The applicant authorizes the bank to debit their account for the transfer amount plus applicable fees according to the SHA, OUR, or BEN charge options selected. Bank use fields at the bottom provide for details of the transaction and signatures from various bank roles to process the request.

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Shrim Master
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266 views2 pages

Print

This document is a remittance application form requesting a demand draft, bankers check, telegraphic transfer, or SWIFT payment. It requests information such as the applicant/sender name and address, amount in words and figures, value date, intermediary bank details (if any), beneficiary bank SWIFT code and address, beneficiary name and address, purpose of transfer, EBOP purpose code, and mode of payment. The applicant authorizes the bank to debit their account for the transfer amount plus applicable fees according to the SHA, OUR, or BEN charge options selected. Bank use fields at the bottom provide for details of the transaction and signatures from various bank roles to process the request.

Uploaded by

Shrim Master
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Date

REMITTANCE APPLICATION FORM


Bank’s Reference No.

Application for Demand Draft Bankers Chq Telegraphic Transfer/SWIFT

DDACC RTGS Ria

Name of Applicant ( Sender )


Sender’s address and Telephone Number

Amount In Words (Please


indicate Currency )
Amount In Figures.

32
Value Date
A
Intermediary Bank (If known) 56
A
Beneficiary’s BANK/SWIFT Code
Beneficiary Bank’s Address
57

Beneficiary

Name -----------------------------------------------------------------------------------------------------------------

Address---------------------------------------------------------------------------------------------------------------
59
Country---------------------------------------------------------------------------------------------------------------

Account Number--------------------------------------------------------------------------------------------------
IBAN

Purpose of Transfer /Remittance Information


(See reverse for reasons) 70

EBOP Purpose Codes Purpose Code Purpose Category


(Please select appropriate from provided list)

MODE OF PAYMENT

Cash

Cheque No .…………………………………
………………………………………………………………..…
Applicant’s Customer Stamp/Signature
I/We authorise the Bank to debit my/our account :
For my/our account and risk and without any responsibility or liability on the part of
Account No:
the Bank subject to the Terms and Conditions on the reverse of this application
Account Name:
which I have read and understood.
This application is only valid when it has been machine validated and signed by Bank’s authorised officer/s
FOR BANK USE ONLY
50000 x Foreign Amount Contract No

20000 x Exchange Rate Nostro Agent

10000 x USD Equivalent Charges SHA / OUR / BEN

5000 x Fee

1000 x Cable
500 x Postage
Total Cash Other
Teller’s Initial TOTAL USD
Staff Branch Branch Branch Branch Branch Branch SWIFT SWIFT SWIFT SWIFT
Teller Frontline Frontline BackOffice OIC, Manager Head Creator Verifier Authorizer
Officer1 Officer2 Office Banking
Operations
Signature
Date/Time

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