|
Request
for Wire Transfer |
||||||||
|
(forward
to Controller's Office) |
||||||||
|
|
|
|
|
|
|
|
|
|
|
Date: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total Amount: |
|
|
|
Type of Currency: |
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Beneficiary
(Payee) Information: |
|
|
|
|
|
|||
|
Beneficiary Name: |
|
|
|
|
|
|
||
|
Address (City,
Country): |
|
|
|
|
|
|
||
|
Bank Account Number: |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
Beneficiary Bank
Information: |
|
|
|
|
|
|||
|
Bank Name: |
|
|
|
|
|
|
|
|
|
Address (City,
Country): |
|
|
|
|
|
|
||
|
Bank Code (Routing)
No.: |
|
|
|
|
|
|
||
|
Swift Account
Number: |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
Contract or Invoice
Number: |
|
|
|
|
|
|
||
|
Contract or Invoice
Date: |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
Purpose of Transfer
or Expenditure: |
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Fund Organization Account Program No. |
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Authorization: |
|
|
|
|
|
|
|
|
|
Printed
Name: |
|
Department: |
Phone: |
|
Signature: |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
IMPORTANT:
Transaction will not be processed unless form is fully completed |
|
|||||||
|
An additional $50 per wire transfer will be charged to your account
to recover various bank fees. |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
For
Accounting use only: |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|