Remittance Request Form

1. Remittance Date (YYYY-MM-DD): 2. Currency: Amount: 3. Purpose of Remittance: If Other, specify:

4. Recipient's Bank Details Bank Name: Branch Name: SWIFT Code:

5. Recipient's Information Name: Address: Account Number:

6. Withdrawal Account Account Number:

7. Recipient Bank Fees:

Fees incurred at the recipient's bank will be borne by the recipient.

8. Notes for the Recipient:

9. Sender's Information Name (Japanese): Name (English): Address: Phone: Date of Birth: