EXPRESSPAY, INC

LOAD WALLET FORM

DATE:
WITHDRAWA
L
FUND TRANSFER REQUEST
FOR APPROVAL*

WITHDRAWAL TRANSFER

AMOUNT : AMOUNT :

BANK DETAILS BRANCH NAME

Account Name** : FROM :

Name of Bank: :
Account Number: : TO :
Branch :

REQUEST FOR APPROVAL

Branch Code/Name :
Depository Bank : Acct No :
Amount Deposited : Branch :
Date Deposited : Est Time :

REQUESTED BY: IDENTIFICATION PRESENTED

ID Type :
Printed Name and Signature

ID Number :
Position

REMARKS:
* For lost deposit slip
** For joint account - kindly indicate the complete account name