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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 Number   (______) ____________________

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

Member Authorization

Member's Signature 


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


For Bank Use Only:

Wire Initiated by: ______________________________

Date: ______________________________

Time: ______________________________

Wire Verified by: ______________________________

Date: ______________________________

Time: ______________________________

Download as PDF file for your convenience: Simple | Original