Remittance Application Form

Remittance Application Form test/09-12-02

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BPI EXPRESS REMITTANCE CORPORATION
A Licensed Money Transmitter
FOR U.S. - BASED REMITTERS

R E M I T T A N C E A P P L I C A T I O N F O R M
(Please print this page)

Please send my remittance via : (click the appropriate box)
Credit to BPI peso account Credit to BPI US$ account Pick up at any BPI/BPI Family Bank branch	Door-to-door delivery to Metro Manila Door-to-door delivery to my province Peso credit to account with another bank Dollar credit to account with another bank

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Amount of Remittance	US$	Check
Service Fee	US$	Check No.
Total	US$
Amount in Words

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Name of Recipient/Beneficiary
(please print)

Beneficiary
Address

Telephone

BPI/BPI Family Bank Account No.

Name of Remitter/Sender
(please print)

Sender's
Address

City

State

Zip Code

Day Time Phone

Night Time Phone

Please enclose ONLY Money Orders or Cashier's Checks payable to BPI EXPRESS REMITTANCE CORPORATION. Photocopy of 2 valid IDs is required for remitters. Exchange rate is based on current rate of date of receipt form. All remittances will be acknowledged upon receipt by BPI EXPRESS REMITTANCE CORPORATION.

RIGHT TO REFUND

     You, the customer, are entitled to a refund of the money to be transmitted as the result of this agreement BPI EXPRESS REMITTANCE CORPORATION does not forward the money received from you within 10 days of its date of its receipt, or does not give instructions committing an equivalent amount of money to the person designated by you within 10 days of the date of the receipt of the funds from you unless otherwise instructed by you.
     If your instructions as to when the money shall be forwarded or transmitted are not complied and the money has not yet been forwarded or transmitted, you have a right to a refund of your money.
     If you want a refund, you must mail or deliver your written request to BPI EXPRESS REMITTANCE CORPORATION at 3550 Wilshire Blvd., Suite 128, Los Angeles, California 90010-2402. If you do not receive your refund, you may be entitled to your money back plus a penalty of up to $1,000 and attorney’s fees pursuant to Section 1810.5 of the California Financial Code.

Signature of Remitter ______________________________

Date ________________________