Date: __________

Transfer/Banker Check Issuance Request

Transfer Banker Check

Your Account Details Customer Name:

Account Number:

Payment Details: Transfer Purpose: Personal Trade Charges: OUR SHA Transfer/Payment Purpose Description:

Amount and Currency in Figures: Currency: Amount:

Amount and Currency in Words: Additional Requirements/Special Requests:

Given that correspondent banks may execute transfers based on beneficiary IBAN/Account Number or on Beneficiary Name even if there is a mismatch between them, I/We confirm under my/our full responsibility that your bank will not be held liable if any of the above information that has been provided and verified by me/us is incorrect. I/We confirm under my/our full responsibility the trueness of the declared reasons for payment/check. I/We agree that the Bank may disclose to any party directly or indirectly involved in this transfer/check, without reverting to me/us any KYC information, under the domestic and international Anti- Money Laundering regulation. I/We discharge your bank from any Responsibility if this transfer/check was rejected, delayed or retained by your bank or your correspondent and I/We authorize you to debit my/our account with any related supplementary charges or fees. I/We confirm that the origin of the goods subject of this transfer, if available, is not from any sanctioned country and that dealing with these goods does not violate any international sanction.

Beneficiary Details Beneficiary’s Name (First, Middle, Last):

Account Number/IBAN:

Beneficiary’s Address:

Beneficiary’s Bank SWIFT/BIC:

Beneficiary’s Bank Name: Origin of Goods: Final Destination of Goods: Country of Transfer:

For Bank Use Only: C/V: Exchange Rate: Ref:

Banker’s Check # : I/We Understand and Accept that BLOM BANK will debit my/our account with the value of the money transfer/banker check whatever the currency of the account is at the exchange rate to be solely determined by BLOM at the time the transfer is processed; and I/We agree that you receive for each transaction, fees and charges that shall be solely set by you, in addition to the commissions and fees due to your correspondent, if any.

Client Signature: Branch Signature: