8 CANADA SQUARE LONDON E14 5HQ

UNITED KINGDOM.

AUTHORITY TO REMIT FORM A/Z

DATE:..................................

BENEFICIARY: ......................................................................................................................……………
ADDRESS:.....................................................................................................................................................
TEL:……………………………………… FAX:………………………………………………………..
EMAIL ADDRESS:………………………………………………………………………………………...
BANK NAME:...............................................................................................................................................
TEL:................................................................... FAX:...............................................................................
EMAIL:.......................................................... SWIFT CODE:…………………………………………
BANK ADDRESS:.........................................................................................................................................
ACCOUNT NO.:............................................. A/C NAME:..............................................................
I hereby authorize H S B C BANK PLC to remit the sum of ................................................................
…………………………………………………………………….. into my account above.

.......................................................................... .....................................................................
BENEFICIARY SIGNATURE BENEFICIARY NAME

CERTIFICATION (FOR OFFICIAL USE ONLY)

I/WE CERTIFY THAT THE ABOVE SIGNATURE AND DETAILS ARE CORRECT

.................................................. ..................................................
SIGN SIGN
AMOUNT

................................................ ....................................................
NAME NAME
(Must be certified along with that of the Head of Administrative Dept.)

(FOR OFFICE USE ONLY)

REMITTANCE BY: BANK WIRE CASHIER’S CHEQUE
CODE REF:...................................................
REMITTANCE:...........................................
FOR OFFICE USE (INTERNATIONAL REMITTANCE OFFICE)
APPLICABLE NOT APPLICABLE PART PAID PAID NOT PAID
1. HANDLING CHARGES
*Beneficiaries affected by the above named condition should clear it relatively before the final Release of the funds and this must be done
within the specified period to avoid displacement of funds into the Suspense Account of The Clearing House.