Formulir Pengiriman Uang
( To Send Money Form )
PENGIRIM / SENDER
First Name
*
Middle Name
Last Name
*
Jenis Kelamin / Gender
*
LK / Male
P / Female
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
Kewarganegaraan / Nationality
*
Pekerjaan / Occupation
*
Hubungan dengan penerima / Relationship With Receiver
*
Transfer Info
Destination (City ,Country)
*
Jumlah Uang yang di kirim / Send Amount
*
Mata Uang / Currency
*
Example ; IDR,USD,SGD
Jumlah (Terbilang) / Amount (In Words)
Example : Ninety Nine Dollars
ALAMAT PENGIRIM / SENDER ADDRESS
Alamat / Address
*
Kota / City
*
Kode Pos / Post Code
*
No Telephone
*
Email
example@example.com
PENERIMA / RECEIVER
First Name
*
Middle Name
Last Name
*
ALAMAT PENERIMA / RECEIVER ADDRESS
Alamat / Address
*
Kota / City
*
Kode Pos / Post Code
*
No Telephone
*
Email Address
example@example.com
BANK INFORMATION
Acc No / IBAN No / No Rekening
*
Bank Name / Nama Bank
*
Bank Address / Alamat Bank
*
Swift Code / BIC No
*
Bank Code / Kode Bank
Routing No
Signatures
Tanggal/Date
*
/
Month
/
Day
Year
Date
Signature With Pen
Upload File Signature
Signature
Signature
Preview PDF
Submit
Should be Empty: