()

SEND MONEY FORM / Branch : / Date :

APPLICATION FORM Remittance In Cash Remittance to Account Amendments Cancellation

/ Payment Method Transfer Amount () Fee of Charge

/ Cash Amount in THB Debit Account No.Amount in Forien Currency

:() Purpose of Fund Transfer (See reverse of this form for guide) Please specify Family Expense () Education Expense (Evidence from educational institution is required.) Goods (Invoice/Purchase Order is required.) Others please specify.

1. / REMITTER'S PARTICULARS Type of CardName ID Card Passport Thailand Driver's LicenceGender Female Male ()

Substitute of identification document (indicating the remitter's date of birth and address)Country

Self Employed Resident Nationality Employed Non-Resident Local Address . Occupation

. Nature of Business

/ Postcode . Tel. No. / Mobile Phone No. Employer Name

Address in Home Jurisdiction

.. Postcode..............................................................................

2. / BENEFICIARY'S PARTICULARS Type of Card Name ID Card Passport () Others, please spcecify. Occupation Nationality Country Please Specify No. / Tel. No. / Mobile Phone No. / If Trasferring the fund to Beneficiary's Bank Account. Bank's Name

3. / REMARKS 5. / FOR BANK USE ONLY

CMT CMT Transaction Referrence No.

Tracer CMT CMT Tracer No.4. / DECLARATION AND SIGNATURE / /G / I/We hereby declare that I/we have read and understood the terms and conditions set forth on the reverse of this form and agree to comply with and be bound by the provisions of the said terms and conditions and any amendments to the same which the Bank may subsequently introduce.

/ // G G G / I/We agree to indemnify the Bank against any and/or all loss, costs, expenses, damages, claims, demands,actions and/or proceedings, which may arise in consequence of this application or document pursuant to this application and is fully responsible for the originality of

documents given to the bank.

Teller's Signature

Authorized Signature

/ Send To Country

Please Specify No

In case of non-Thai remitter transferring the fund of THB 50,000 or more, the remitter shall have:

A A 5 A A

In case of non-Thai remitter transferring the fund under THB 50,000, the remitter's address in home jurisdiction is required.

................................ / Applicant's Signature

** A - I 1 I ** Please fill in additional information in case of transferring the fund of THB 100,000 or more.**

Place of Birth

Document showing address in home jurisdiction or certificate of address in home jurisdiction issued by the employer; and

Document showing residential address or certificate of residential address issued by the employer

A I 5 AI A I

Beneficiary's Account No.

Local Address Date of Birth

/ COMPUTER VALIDATION

Date of Birth

A

Place of Birth / Payout Agent Name

// I/We authorized the bank to debit my/our account as per the requirement above.

Driver's Licence