leftovercurrency
EXCHANGE FORM
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To exchange your foreign currency and coins, fill out this exchange form and send it, along with your
banknotes and coins to our address:
L.O.C. - 3rd Floor - 207 Regent Street - London W1B 3HH - United Kingdom
This form can be completed electronically or by hand. Fill in your contact details and preferred
payment method in part A. Indicate the amount per currency submitted for exchange in part B. Sign
and date the declaration in part C. Send the completed form with your notes and coins to the
address above. Upon receipt of your leftover currency, we will send you a confirmation email. You
will receive payment within five days of receipt.
(A) PAYMENT DETAILS AND PREFERENCES
Please write clearly in CAPITAL letters:
Title (Mr/Mrs/Ms/...)
Last name, first name
Street address
(address line 2)
City/town
County/state/province
Postal code/ZIP code
Country
Email address
Preferred payment method:
Preferred payout currency:
Bank Transfer (fill in A1)
Cheque (fill in A3)
Pound Sterling
Euro
PayPal (fill in A2)
Charity (see A4)
US Dollars
_______________
(A1) Bank account details:
(A2) Email address to receive PayPal payment:
Account holder name:
Sort code/BIC/routing
(A3) Make cheque payable to:
Account number:
or
IBAN:
(A4) Donate to charity:
We will donate the exchange value to the charity of
the month. Details on www.leftovercurrency.com/charity
leftovercurrency
EXCHANGE FORM
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(B) AMOUNTS PER CURRENCY
Write down the amounts per currency submitted for exchange.
CurrencyName
BANKNOTES
COINS
CurrencyName
BANKNOTES
COINS
American Dollar
USD
Singapore Dollar
Australian Dollar
SGD
AUD
Slovak Koruna
Austrian Schilling
SKK
ATS
Belgian Franc
Slovenian Tolar
SIT
BFR
Brunei Dollar
Spanish Peseta
ESP
BND
Canadian Dollar
Swedish Krona
SEK
CAD
Croatian Kuna
Swiss Franc
CHF
HRK
Cypriot Pound
Thai Baht
THB
CYP
Czech Koruna
Turkish Old Lira
TRL
CZK
Danish Krone
Turkish Lira
TRY
DKK
Deutsche Mark
UAE Dirham
AED
DEM
Dutch Guilder
NLG
Egyptian Pound
EGP
Estonian Kroon
EEK
Euro
EUR
Finnish Markka
FIM
French Franc
FRF
Greek Drachma
GRD
Hong Kong Dollar
HKD
Hungarian Forint
HUF
Indian Rupee
INR
Irish Pound
IEP
Israeli Shekel
ILS
Italian Lire
ITL
Japanese Yen
JPY
Latvian Lats
LVL
Lithuanian Litas
LTL
Luxembourg Franc
LUF
Maltese Lira
MTL
Moroccan DIrham
MAD
New Zealand Dollar
NZD
Norwegian Krone
NOK
Oyster Card
TfL
Philippine Peso
PHP
Polish Zloty
PLN
Portuguese Escudo
PTE
Pound Sterling
GBP
England
£
Channel Islands
£
Gibraltar
£
Isle of Man
£
Northern Ireland
£
Scotland
Romanian Old Lei
ROL
Romanian Lei
RON
Saudi Riyals
SAR
£
(If you send other currencies, please list the amounts below)
(C) DECLARATION
I declare that I have obtained all submitted banknotes
and coins in a lawful manner, and not by any criminal
act. I confirm that I am entitled to offer these
banknotes and coins for exchange, under the
conditions stated in the Terms and Conditions,
which can be found at www.leftovercurrency.com/
terms-and-conditions.
I have read, understood and agree to these terms and
conditions. I hereby declare that all the information
provided in this form is true to the best of my
knowledge and belief.
date:
signature: