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1. Transfer amount: Currency (USD, EUR)

Amount (in numbers)

Amount (in words)

2. Client information (you have to be the main account holder of the account to be debited for the transfer) Account number: Identity document number (Passport, national ID): Name and Surname: Client Number: Complete Address: Telephone (mobile and/or landline):

3. Intermediary bank information (optional) Intermediary Bank: City and Country: SWIFT*: ABA/FED/Routing Number**: BLZ**: Canadian Routing Number: Sort Code**:

4. Beneficiary Bank information Beneficiary Bank: City and Country: Beneficiary Bank Branch (optional): Beneficiary Bank’s account number in the Intermediary Bank: SWIFT*: ABA/FED/Routing Number**: BLZ**: Canadian Routing Number: Sort Code**:

5. Beneficiary Information Address: Beneficiary’s account number***: Beneficiary’s name: Identity document number (in case the beneficiary does not have an account – optional):

6. Payment details Purpose of transfer:

General conditions By means of the client’s signature, the client declares to know and accept the following general conditions with respect to his funds transfer request: 1. We do not assume the responsibility for possible mistakes or delays in the procedure and interpretation of the request derived from the information provided by the client. 2. It is established that if the payment did not get to be performed by causes not liable to us, the paid commission and expenses will not be reimbursed. 3. The commission charged by us does not include the expenses of third parties. Therefore the paying bank(s) and/or intermediary(ies) and/or its/their representative(s) will be able to discount their commissions from the transferred amount to the Beneficiary. 4. The person requesting the transfer of funds must be the account holder. (*) SWIFT authentication code of the bank is alphanumeric and consists of either 8 or 11 characters. (**) ABA, FEDWIRE, ROUTING NUMBER are all the same and consist of 9 digits, BLZ 8 digits, SORT CODE 6 digits and CHIPS UID 6 digits (***) Beneficiary’s account: IBAN in Europe, CLABE in Mexico (18 digits)

___________________________________ Client’s signature

En pegaso website transfer request 14 08 2013  
En pegaso website transfer request 14 08 2013