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PAYMENT RELEASE FORM

DATA  OF  THE  TITULAR

NAME OF THE BENEFICIARY:

TEL: AND FAX NUMBER: (MOBILE LINE)

DATE OF BIRTH:

OCCUPATION/ORAGNISATION

ADDRESS:

COUNTRY/STATE/CITY

AMOUNT: (€)

PRIVATE EMAIL ADDRESS:

I WANT TO BE PAIDED BY:  (a ): BANK TRANSFER      (b)  DRAFT       (c) CASH

BANK INFORMATION

BANK NAME                                                                                                                                                 

BANK ACCOUNT NUMBER:

ROUTING/SWIFT CODE:

BANK ADDRESS

BANK PHONE NUMBER

BANK FAX NUMBER:

CITY

STATE

ZIP:

I………………………………………………………. HEREBY DECLARE THAT THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE.. I HEREBY GIVE THE PROCESSING AND TRANSFER OF MY FUND TO THE DESIGNATED BANKING INFORMATION STATED ABOVE ON MY BEHALF.
SIGNATURE. ...........................................  DATE.........................................................................                                               

                                      FOR BANK OFFICE USE ONLY

NAME OF THE BENEFICIARY:

TRANSFER CODE:

TRANSFERING OFFICER:

NAME OF THE BANK TO BE TRANSFERED:

AMOUNT TO BE TRANSFERED

DATE OF TRANSFER:

:

SIGNATURE...................................................          DATE:..............................................