ВНИМАНИЕ!
Данную форму необходимо заполнять в соответствии с образцом.		  
 
OUTGOING INTERNATIONAL WIRE REQUEST
Date:  / /   Wire Requested by (circle one):   Broker   Customer
PFG Account Number: 
PFG Title:
 
 
  Amount to be Wired: $   Check here for Entire Account Balance  
Wire Transfer Charge: $    
Amount to Debit Acct:   $   (Wire + Charge)
 
 
Please transmit funds to Customers Bank:
Name of Bank:
Branch or Location:
City, Country:
Banks Swift Code (mostly letters): 
Exact Account Name at Bank:
Exact Account Number:
 
If Account is at another Institution, put your account info at Institution below:
Account Name:
Account Number:
Special Instructions: 
 
Approved by:    Sequence #: 
 
 
Обязательно укажите Ваши контактные данные:
E-mail: *
Подтвердить E-mail:  *
Телефон: *
Мобильный:
ICQ:
Skype:
 
* Отмеченные поля обязательны для заполнения.
 
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