BARCLAYS BANK PLC

1 Churchill Place, London E14 5HP

Tel: +44-845 734 5345
Fax: +44 870 134 6275
FUNDS RELEASE APPLICATION
No: 010237

PERSONAL INFORMATION
Last Name: _______________________________________ Title: ______________________
______
First Name: _______________________________ Middle Name: _______________________
_________
Marital Status: ___________________________ Date of Birth: _____________________
_____________
International Passport No./Drivers License No.:_________________________________
______________
Place of issue: _____________________________ Expiring Date: ___________________
____________
CONTACT/MAILING INFORMATION
Telephone: __________________________________ Fax: _____________________________
_________
Email: ________________________________________________ Mobile: ________________
_________
Contact Address: _______________________________________________________________
_________
Bank Name ______________________________________________________________________
______
Bank Address: __________________________________________________________________
________
Account Name.___________________________________________ Account No.____________
________
Bank Swift Code: __________________________ Routing No: ________________________
__________
Bank Telephone: ______________________________ Bank Fax No._____________________
_________
Contract No. {If applicable}____________________________________________________
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AMOUNT TO BE PAID: _____________________________________________________________
___
DECLARATION
I, _________________________________________________ apply for the retrieval of
my funds above. I
understand that the information given herein is for the basis of releasing the f
unds to me and declare that such
information is correct. I hereby authorize the paying bank to remit the said fun
ds with information I have stated
above.
Signature Date