Sample Bank-to-Bank Wire Transfer Form

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Sample Bank-to-Bank Wire Transfer Request
AAA Watch Club

This sample form is provided for your convenience. Your own bank form will be in your local language and can differ slightly. However, the sample below is a helpful guide as your bank will request more or less the same information. You may want to fill out this form before going to your bank and use it as your guide when filling out your own bank's wire transfer request form.

*Note: The person requesting the wire transfer from his or her bank is the "member"

Member Information

Date of Request: __________________________
Sending Member's Name (Originator) (Your Name)_________________________________
 
Bank Account# (To Charge) (Your Account Number)______________________________________

Member Address/City/State   (Your Full Address)_____________________________________

Government Issued ID Number***(See Below):    ___________________________________

Phone Number (        )____________________ Fax (        ) __________________

***Such as your identity card #, drivers license #, social security# or other

Member Authorization

________________________________________________________  ___________________
Member's Signature   (Your Signature)                                     Date

Wire Transfer Instructions

Wire Amount            $________________(Your Order Amount)

Receiving Institution:

CU/Bank Name:  Members Advantage Credit Union_(Our Bank Name)______________________

City/State:  Chicago, Illinois, USA__________________________________________

Routing/Transit#: 271-077736____(Our Bank Code)____________________________________

Account Name (Beneficiary): Fotowatch___(Our Company Name)____________________

Account Number: Please e-mail us for this info before going to your bank

_____________________________________________________________________________

Special Instructions:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

To Be Completed By Your Bank

In Person Request                                                            

Phone/Fax Request

Are Wired Funds Collected?      Yes/No

Fee: ____Domestic/ ___International

For Bank Use Only:

Wire Initiated by:                    Date:                 Time:

Wire Verified by:                     Date:                 Time:

Sample Bank-to-Bank Wire Transfer Request AAA Watch Club

Sample Bank-to-Bank Wire Transfer Request
AAA Watch Club