Wire Transfer Form

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Wire Transfer Form
Department Order Number_________________________ Signature___________________
Contact Telephone Number__________________________
Date____________________
_____________________________
Type of currency to be wired USD, EUR , GBP, CAD Other
$____________________________________
Amount
Beneficiary Account Information
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Swift/Chips/ Account Number
___________________________________________________
Bank Name
______________________________________________________
Address
______________________________________________________
Address
______________________________________________________
Address
Beneficiary Bank Information
All wires to Mexico must have the CLABE number; the wires cannot be process if the CLABE number is not
provided.
________________________________________________________
IBAN Number
__________________________________________________
Bank Account Number
______________________________________________
Payee’s Name (Beneficiary )
_______________________________________________________
Payee’s Address
_______________________________________________________
Address
_______________________________________________________
Address
Reference / Invoice Information
Please call Barbara Claiborne at 827-1882 or Susan Brown at 828-2140 if you have any questions regarding out-going wires.

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