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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: