Western Union Request Form printable pdf download

Western Union Request Form

MEMBER INFORMATION

Member # ___________________________________________ From Account _________________________________________

Member Name _____________________________________________________________________________________________

Member Address ___________________________________________________________________________________________

Member Phone # ____________________________________ Member Cell Phone # ____________________________________

Social Security Number _____________________________ Member Email ____________________________________________

Amount to Be Sent $_____________________

Funds Verified By: _________________ Fee Amount: _________________ Approved By: _________________

DESTINATION —  DOMESTIC  INTERNATIONAL

Destination City ___________________________________________ State/Country _____________________________________

Identification Available _______________________________________________________________________________________

BENEFICIARY (Recipient) INFORMATION —  SELF  THIRD PARTY

Beneficiary’s (Recipient’s) Name _______________________________________________________________________________

Address ___________________________________________________________________________________________________

Phone # ___________________________________________ Cell Phone # ___________________________________________

I, hereby authorize Corporate America Family Credit Union to transfer funds by Western Union as shown above. I understand that my account will be debited for the

amount of the funds transfer plus applicable fees. I agree to hold Corporate America Family Credit Union harmless if the funds are not received and credited due to

incorrect information provided above.

Member’s Signature ____________________________________________ Date ______________________ Time ____________

STAFF Use:

Teller # ________________

Recv’d:

In Person

Phone

Fax

Mail

What identification was verified __________________________________ Date _______________ Time ______________

______________________________________________________________________________________________________________________

Operations Department Use