Corporate Banking
www.rmb.co.za
Reg. No. 1929/0011225/06
An Authorised Financial Services Provider and Credit Provider (NRCP20)
Global Outward Payments
(Bank Sale)
To FirstRand Bank Ltd (acting through RMB Corporate Banking)
Branch Name
Branch Code
Hub Name
Hub Code
Date
C C Y Y M M D D
I/We hereby request that you (“the Bank”) attend to my/our request for the following transaction on my/our behalf:
Draft
Swift Transfer
Part 1: Resident Entity Details (Only)
(If resident entity complete Part 1,3,5,6,7 and 4 (if applicable))
Legal /Registered Entity Name
Registration No.
Trading Name
Full Business Address
Suburb
City
Province
Code
Postal Address
Postal Suburb
Postal City
Postal Province
Postal Code
VAT No. (Applicable to cat codes:101/01 to 101/10, 102/01 to 102/10, 103/01to 103/10, 104/01 to 104/10,105, 106)
Tax No. (Applicable to cat codes:101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10,105, 106)
Contact Name (First Name and Surname)
Telephone No.
Fax No.
-
Part 2: Resident Individual Details (Only)
(If resident individual complete Part 2,3,5,6,7 and 4 (if applicable))
First Name
Gender
-
Email Address
Surname
Male
Female
Y N
RSA Resident
Date of Birth
C C Y Y M M D D
ID No.
Tax No. (Applicable to cat codes: 101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10, 105, 106, 511/01 to
511/07, 512/01 to 512/07, 513)
Tax Clearance Certificate Reference No.(Applicable to cat codes: 512/01 to 512/07, 513)
Passport No. of Resident Traveller
Passport Country
Temporary Resident Permit No. (In the event that the foreign national is a temporary resident in RSA)
Foreign ID No.
Foreign ID Country
(Excluding foreign travellers to RSA)
(If foreign ID No. supplied)
Full Residential Street Address
Suburb
City
Province
Postal Code
Postal Address
Postal Suburb
Postal City
Postal Province
Postal Code
Contact Name (First Name and Surname)
Telephone No.
-
Fax No.
-
Email Address
Signatories to initial here
Part 3: Beneficiary Details
Full First Name of Individual
Surname of Individual
Legal Entity Name
Gender (If individual)
Male
Female
Residential/Business Street Address
Suburb
City
Province/State
Zip Code
Country
Name of Bank
Branch Name
Bank Account No./IBAN
Swift Code/Routing No
Country from which goods/services were obtained
Part 4: Third Party Details (Resident Third Party involved in the transaction)
(if applicable)
(If more than two (2) resident third parties involved in the transaction, attach an addendum to the payment instruction)
Third Party No.
Third Party No.
CCY
CCY
Amount
Amount
Full First Name and Surname (if an individual)
Legal Registered Entity Name
Registration No. (If Entity)
Date of Birth (If Individual)
Gender (If Individual)
C
C
Y
Male
Y
M
M
D
D
Female
C
C
Y
Y
M
Male
M
D
D
Female
Street Address
Suburb
City
Province
Postal Code
Postal Address
Suburb
City
Province
Postal Code
ID No. (If Individual)
Temp. Resident Permit No. (If Individual)
Passport No. (If Individual)
Passport Country (If Individual)
Contact Name (Full Name and Surname)
Tel. No.
-
-
Fax No.
-
-
Email Address
Tax No.1
VAT No.2 (If entity)
Customs Client No.3
Tax Clearance Certificate Reference No.4
1. Applicable to cat codes: 511/01 to 511/07, 512/01 to 512/07, 513, 101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10, 105, 106
2. Applicable to cat codes: 101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10, 105, 106
3. Applicable to cat codes: 101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10, 105, 106
4. Applicable to cat codes: 512/01 to 512/07, 513
Signatories to initial here
Part 5: Financial Surveillance Reporting Details
Third Party No.
(If more than one (1) split involved in the transaction, attach an addendum to the payment instruction)
1. Category / Sub
Amount
Import Control No.(MRN) (Applicable to cat codes: 101/01 to 101/10, 103/01 to 103/10, 105, 106)
Customs Client No.(CCN) (Applicable to cat codes: 101/01 to 101/10, 102/01 to 102/10, 103/01 to 103/10, 104/01 to 104/10, 105 and 106)
Transport Document No. (Applicable to cat codes:103/01 to 103/10)
Loan Ref No. (Applicable to cat codes:106, 309/04 to 309/07)
Loan Tenor (Maturity Date) (Applicable to cat codes:810, 815, 816, 817, 818, 819)
C
C
Y
Y
M
M
D
D
On Demand
Y
N
Loan Interest Rate (Applicable to cat codes: 309/04 to 309/07, 810,815, 816, 817, 818, 819)
Value Date
Wish to Purchase Foreign Currency:
C
C
Y
Y
M
M
D
D
Currency
Foreign Amount
Amount in Words
ZAR Equivalent
Amount in Words
Details of Payments Not Classified (cat codes 830)
SARB Authority Ref No.
SARB Authority No.
(e-Docs No. outlined in formal response)
(Where approval had to be obtained from the SARB)
AD Internal Authority No.
Date
(In the case where FirstRand provided internal authority)
C
C
Y
Y
M
M
Institution where the authority is held
Part 6: Settlement/Disbursement Instructions
(Where more than one settlement method is to be used, please ensure appropriate boxes are marked)
a.
You are hereby authorised to debit my/our account no.
Cheque
Savings
Account Name
Currency
b.
Z
A
R
Amount
Debit my/our CFC/FCA account no.
Account Name
Currency
c.
Amount
You are hereby authorised to draw down against FEC no.
Currency
d.
Amount
Other (Please specify details, e.g. currency to currency)
Currency
Amount
Deal no. (a – d) (If applicable)
Rate
Contact Name (Full Name and Surname)
Telephone No.
Please tick if you wish to convert at Spot
Please tick if you wish to be contacted before an exchange rate is booked
Please tick if you wish to receive a copy of the Settlement Confirmation
If this transaction relates to a Letter of Credit and/or Foreign Bill of Exchange please supply details
Account No. to be Debited for Charges (Charges Account)
Details of charges
SHA: Charges are
shared
BEN: All charges are paid for by the
beneficiary
OUR: All charges including overseas
charges are paid for by RMB client
Signatories to initial here
D
D
Part 7: Declaration And Signature
1. We acknowledge and agree that certain payments may, through the operation of international law, the laws and regulations of other jurisdictions
and/or international or governmental practice (whether or not having the force of law) be prohibited, confiscated, embargoed, withheld or
otherwise prevented from being made before such payments have reached the intended recipient(s).
2. We accordingly indemnify the Bank against and hold it harmless from any and all claims for payment, interest or penalty, damages, losses and legal
costs which we or the Bank may suffer or incur, directly or indirectly, as a consequence of:
(a) the payment being prohibited, confiscated, embargoed, withheld or otherwise prevented from being made, as a result of the circumstances set
out in 1. above; and
(b) the Bank adhering to our request to process the payment instructions or by virtue of the Bank exercising its authority to debit our account as set
forth in this document, save in the circumstances where the Bank was grossly negligent.
3. We note that from time to time, the Bank will be obliged to disclose information relating to this instruction to its local and international counterparty
banks for purposes of such counterparty complying with its rules, regulations and other legitimate duties and we hereby agree and consent to the
Bank making such disclosure.
We declare that the information contained in this document is true and correct.
Signed at
on this the
day of
20
For and on behalf of:
Signature
Signature
(who warrants that he/she is duly authorised)
(who warrants that he/she is duly authorised)
Part 8: For Office Use Only
Rate of Exchange
Rand Equivalent
Plus Commission (including VAT)
Total Value
IB No.
TRN Reference No.
Swift Country Code
Rulings Section
Received Stamp
Excon Authority Stamp
Other
Signatories to initial here