AGENT LOCATION

HOW TO FILL OUT THE MONEY TRANSFERAPPLICATION FORM

THIS IS

ENGLISH

英語

HOW TO COMPLETE THE MONEY TRANSFER APPLICATION FORM• Please fill out the Money Transfer Application Form in BLOCK LETTERS.

© 2016 Western Union Holdings, Inc. All Rights Reserved.

12

46

910

11

18

3

5

78

16

17

121314

15

　 Your Information• Fill in your full name using English alphabet as it appears on your identification document.

1 　 Address• Japanese Nationals & Foreign Residents in Japan: The address must be the same as the address indicated on your identification document.

• Non-Residents: The address needs to be provided according to your passport or hotel confirmation in Japan.

2

　 Country of Birth• The name of the country where you were born.

4

　 Nationality• Your current nationality.

6

　 Destination countries: the U.S.A.,　 Mexico or Canada• Make sure to provide name of city and state where the Recipient will collect the funds, if funds are transferred to the U.S.A., Canada and Mexico.

• This information may be different from the Recipient’s address (Country, State and City).

9

　 Transaction Purpose• Choose one of the purposes.

10

　 Test Question• Test Questions and Answers may be required for Recipient verification purposes in certain countries or if the principal amount does not exceed U$1,000 (or local equivalent currency) in addition to MTCN.

11

　 Date• Transaction date in the day-month-year order.

18

　 Contact Phone Number• Your home phone number or your mobile phone number.• Provide your mobile phone number if you would like to receive an SMS notification to inform that a money transfer was collected successfully by the Recipient.

3

　 Individual Number (My Number)• Your Individual Number (My Number) with 12 digits. (Japanese Nationals and Foreign Residents only)

For more details please visit http://wu-japan.com/mynumber/en

5

　 Sending amount• Provide the transfer amount of your money transfer.• Please Choose the currency JPY (Japanese Yen).

7

　 Recipient’s Name• Fill in the Recipient’s full name using English alphabet. The Recipient’s name must be the same as the name indicated on the Recipient’s identification document, which must be shown while receiving the funds; otherwise, the funds will not be paid out.

8

　 Direct to Bank Account• Direct to Bank Account information varies depending on destination countries. For more details, please refer to the NEXT PAGE.

12

　 Bank Name• Fill in the Recipient’s bank name. (It cannot be abbreviated)

13

　 Beneficiary Name• Fill in the Recipient's name as registered with his/her bank.

14

　 BIC/IFSC/IBAN• Fill in the Bank Identifier Number for the Recipient's bank account.

15

　 Confirmation• After confirming the content inside the box, please make sure you check this BOX□. Without your agreement, money transfers cannot be processed.

✓

16

　 Signature• This must be the Sender's signature.

17

REQUIRED RECIPIENT’S BANKING INFORMATION BY COUNTRYFOR THE DIRECT TO BANK ACCOUNT SERVICE

AUSTRALIA

© 2016 Western Union Holdings, Inc. All Rights Reserved.

Bank NameBeneficiary Name (Bank Account Name)Bank Account Number: 1-9 CharactersBranch Number: 6 Characters

BRAZIL

Bank NameBeneficiary Name (Bank Account Name)Bank Account NumberBank Branch NumberAccount Type

CHINA

Bank NameBeneficiary Name (Bank Account Name, Pin Ying)Bank Card Number (UnionPay debit cardaccounts must start with 62, 14-19 digits)

INDIA

Bank NameBeneficiary Name (Bank Account Name)Bank Account NumberRouting IFSC: 11 Characters

INDONESIA

Bank NameBeneficiary Name (Bank Account Name)Bank Account Number

PAKISTAN

Bank NameBeneficiary Name (Bank Account Name)Bank Account Number: 20 Characters

PHILIPPINES

Bank NameBeneficiary Name (Bank Account Name)Bank Account Number

THAILAND

Bank NameBeneficiary Name (Bank Account Name)Bank Account Number: 1-34 Characters

THE UNITED STATES OF AMERICA

Bank NameBeneficiary Name (Bank Account Name)Bank Account NumberABA Routing Number: 9 Characters

CPF (Tax ID Number): 11 CharactersDate of BirthPhone NumberMobile Phone Number

Postal CodeAddress (City, State, Country)Mobile Phone Number

Bank Branch Name/AddressPhone Number

Postal CodeAddress (City, State, Country)Phone Number

SEND TOACCOUNT

1

234

1

2 673

4

5

1

26789

345

12

4

3

1

23

4

5

1

2

5

673

4

1

2

3

1 4

23

1

23

1234

12 6

73

123

4

5

12

6789

3

123

123

4

4

12

3

4

123

45

167

234

5

5

Receiver's City and Street Address

Mobile Phone Number (must start with “1” and 11 digits long)