Complete the form and present with valid ID. and Address Proof Toll ...
Complete the form and present with valid ID. and Address Proof Toll ...
Complete the form and present with valid ID. and Address Proof Toll ...
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Company Copy<strong>Complete</strong> <strong>the</strong> <strong>form</strong> <strong>and</strong> <strong>present</strong> <strong>with</strong> <strong>valid</strong> <strong>ID</strong>. <strong>and</strong> <strong>Address</strong> <strong>Proof</strong> <strong>Toll</strong> Free: 1800-425-1851(TO BE USED BY AGENT)Money Transfer Control No. (MTCN):Amount Expected: __________________________________________________________________City, State / Province, Country money sent from_________________________________________Receiver/Beneficiary DetailsNames(s)_____________________________ _________________________________First Name Last Name Account Code Operatoe NumberMale FemaleCurrent <strong>Address</strong>_________________________________________________________________________Building Name/Plat No._______________________________________________________________________________________Street / Road Name + Area_________________________________________________________________________CityState/ProvincePIN / Postal CodeContact Tel. # (L<strong>and</strong>line)_________ ______________________ Contact Mobile # _________________STD CodeDate of Birth____________________________ Country of Birth_________________________________Purpose of Transaction Personal Use Family Maintenance Medical EducationDate<strong>ID</strong> Number<strong>ID</strong> Type<strong>ID</strong> Issue CountryDate of ExpiryTimePhoto IdentificationOccupation Salaried Self employeed/Business Student RetiredDate of Birth of <strong>the</strong> ReceiverO<strong>the</strong>rs (specify)________________________________________________________________________<strong>Address</strong> <strong>Proof</strong> Collected?Relationship to sender Fa<strong>the</strong>r Mo<strong>the</strong>r Wife Husb<strong>and</strong> Child Yes NoBro<strong>the</strong>r Sister Friend O<strong>the</strong>rs (specify)___________________________________Beneficiaries who are not resident in India are required to fill <strong>the</strong> below-mentioned details:Parmanent address_____________________________________________________________________________________________________________________________________________________________City_______________________ Province/State_______________________ Country______________________Contact Tel.# __________________________________________ Mobile #______________________In country of residence Country/Area CodeForeigners (tick only if applicable)I am / have been entrusted <strong>with</strong> public functions(Heads of Government or working for judiciary/armed forces/state-owned companies)Visa <strong>valid</strong> upto<strong>ID</strong> Number<strong>ID</strong> Type<strong>ID</strong> Issue CountryDate of ExpiryMoney Transfer Control Number (MTCN):Cheque No.2nd Photo Identification (if applicable)Payout AmountAmount/Currency sent by <strong>the</strong> sender:I am / have been a member of political party in my countrySender DetailsFX RateDate FilledName(s)_________________________________ ____________________________________________Originating City/CounterFirst Name Last Name Agent's SignaturesMale Female<strong>Address</strong>________________________________________________________________________________________________________ _____________________________ __________________________City State/Province Postal Code________________________ Contact Tel. # _________________ __________________________CountryCountry Code/Area CodeCERTAIN TERMS AND CONDITIONS GOVERNING THE MONEY TRANSFER SERVICE YOU HAVE SELECTED ARE SET FORTH ON THE BACK OF THIS FORM.BYSIGNING THIS FORM, YOU ARE AGREEING TO THOSE TERMS AND CONDITIONS IN ADDITION TO THE TRANSFER FEE. WESTERN UNION AND ITS AGENTS ALSO MAKE MONEY FROMTHE EXCHANGE OF CURRENCIES.I DECLARE THAT THE REMITTANCE RECEIVED IS A PERSONAL REMITTANCE TOWARDS FAMILY MAINTENANCE AND IS NOT TRADE RELATED OR FOR PURCHASE OF PROPERTYINVESTMENTS OR FOR CREDIT TO THE SENDER'S/REMITTER'S NRE/FCNR ACCOUNT OR DONATIONS/CONTRIBUTIONS TO CHARITABLE ORGANISATIONS.I DECLARE THAT WITHIN THIS CALENDAR YEAR, I HAVE NOT RECEIVED MORE THAN 12 REMITTANCES UNDER THE GOVERNMENT OF INDIA MONEY TRANSFER SERVICE SCHEME.I WARRANT THAT THE INFORMATION SHARED BY ME IN THIS FORM IS TRUE AND CORRECT.Received Cash/Cheque Rs. :_________________________ Date :_________________ Customer Signature :__________________________THIS SERVICE IS GOVERNED BY THE GOVERNMENT OF INDIA MONEY TRANSFER SERVICE SCHEME APPLICABLE TO INDIAN NATIONALS AND FOREIGN TOURISTS VISITING INDIACopyright © 2010 WESTERN UNION HOLDINGS, INC All Rights Reserved
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