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National llank I"irnitecl
Bangshal Road Brancll
ttTGS-/BEF"fh[ Fund'fransfer Reqnest Application
Date: Payment Through: Currency: BDT USD CBP I:UR .l YI'J
Applicant's Details:
AIC No.: I
Type FC CD SB S].ID
Name of'the Applicant:
Address: ..,.,.......... r.. r. rr. ...Street:".
Lanc! Phongt.. ", i.., ..... Cell Phong: o........
:...o,..,..
Ileneficiary's Details :
A/C No": r I
Type FC CD SB SND
Beneficiary' s Bank Narne: o. o......Branch Namel .............., o...... o....City: ...... t
o o
Routing No.: Reference/Purpose of Remittancel ...... ".
Name of thg Rengficiary: ,.,............
Acldress: o. o.r e. r.. r.. t..... e .. o.......... r r.. r
' r. ........... Street:. t.. t..... r ......... c......Cityl
e n.... ',
LaDcl Pl t one l o.,. . ., . oi , . r. . . .. . . tc. r r . . r. . . . r r. e ,..o.e Cell Phone: .............o..,o-
Amount to be Rgnrittetlr ..nn.....,,....o. r.. r........ e r..r!.....Charges:. '... r. r re .... r... r....... .....Total:
'I'otal Amount in Wordsr...nc.,.,........
IAYe agree to the terms and conditions printcd on the overleaf.
Please eject RTGS/BEFTN Transaction nnd credit the proceeds to the beneficiary. Chequc No. _is enclosed, if applicable.
Customcr's Signaturc
Distinctive Rernittance Number (For Bank's Use)e tlD i\', l"{ YYYy Serial No.
Verified thc Details and Crctlited the Amount to RTGS Settlement Account Service Charges Collected nrrd Credited to Charge &Commission Accour{.
Authorized Signature Authorized Signature
\
\
Bapkef's Acknowledgement (Customers Copy)
On behalf of National Bank Ltcl, Bangshal Road Branch we have received appropriate
writtetiinstructioncontainsChequeNo..............TK
InWord... 0a only f,rom
Mr.AyIs.Ayf-s for RTGS/BEFT}{ service"
l aar a !a t r a t l a aar t r a a !r a 3 t arr t | ! l r t I a t ra t 9 t
Authonized Signa(ure
