RED TAB SCHOLARS PAYMENT REQUEST FORM



All information except signatures must be provided in English. Completeness and neatness ensure your information will be reviewed properly. Return completed form by fax or mail as instructed in your official scholarship notification letter. For your own security, do NOT send this information via email.WIRE TRANSFER REQUEST FORMName of Scholarship: ________________________________________________________________________________Student Name: ______________________________________________________________________________________Contact your bank to ensure you are providing the correct required information. This information must be updated before each wire transfer.Note: The accuracy of the data you provide below is very important. Check your information to prevent delays.1. Receiving Bank: (COMPLETE BANK NAME, no abbreviations)2. Bank Address:(Street Address, City, State/Province, Country)3. Currency preference (check one): □ LOCAL CURRENCY □ $ UNITED STATES DOLLARS (NOTE: See instructions for a list of countries where only United States Dollars can be wired.)4. CLABE # (MEXICO ONLY):_____________________________________________________________________5. IBAN: ______________________________________________________________________________________6. SWIFT: _____________________________________________________________________________________7. Routing # (UNITED STATES ACCOUNTS ONLY) ____________________________________________________8. Bank Branch Code (AUSTRALIA AND SOUTH AFRICA ONLY):_____________________________________9. Financial System Routing Code (INDIA ONLY): __________________________________________________10. Bank Account #:_______________________________________________________________________________ (Bank account must be active when funds are wired.)11. Bank Account Holder’s Name: ____________________________________________________________________ (Include the entire name in the same order as printed on the account holder’s bank documents. Do not abbreviate.)12. Bank Account Holder’s Telephone Number: _____________________________________________________13. Bank Account Holder’s Home Mailing Address: (United States Envelope Format) ________________________________________________14. Scholarship Recipient’s Current Email Address: ___________________________________________________15. Scholarship Recipient’s Signature: _____________________________________________________________INSTRUCTIONSWIRE TRANSFER REQUEST FORMProvide the complete name of the bank that you will use to receive your scholarship.Provide the bank’s address including building#, street, district, city, state or province and country.Indicate your currency preference by checking one of the boxes. See the list below for countries where only United States Dollars can be wired. If your bank is located in a country shown on the list below, verify that your bank account can receive ($) USD.Provide a CLABE* number if your bank is in MEXICO. Provide an IBAN* if applicable. Provide your bank’s SWIFT CODE*.Provide your bank’s ROUTING NUMBER* (United States Only).Provide your bank’s branch code only if your bank is in Australia or South AfricaProvide your banks Financial System Routing Code only if your bank is in IndiaProvide your bank account number.Bank account holder’s name. Completely copy the name shown on your account documents. For China: do not change the order of first and last name.Bank account holder’s telephone numberBank account holder’s mailing address should be put in English and in the order of English envelope format. Scholarship recipient’s current email address.Scholarship recipient’s signature.*You can find the CLABE number, IBAN, SWIFT CODE or ROUTING NUMBER at your bank branch location.If your bank is located in one of the countries listed below, your scholarship funds will be wired to your account in United States Dollars. It is your responsibility to be sure your bank account can receive ($) USD.__________________________________________________________________________________________ANGOLAARGENTINA ARMENIAAZERBAIJANBANGLADESH BELARUSBERMUDA BHUTANBOSNIABRAZIL BURUNDICAPE VERDECHILE CHINA COLOMBIA COMOROSCOSTA RICA DJIBOUTIDOMINICA ERITREAGAMBIAGEORGIAGUATEMALAGUINEAHONDURAS INDONESIA JAMAICA KENYA KOREA LAO PEOPLE’S DEMOCRATIC REPUBLICLESOTHOLIBYAN ARAB JAMAHIRIYAMACAUMACEDONIAMADAGASCARMALAWIMALAYSIA MAURITANIAMAURITIUS REPUBLIC OF MOLDOVA MONGOLIAMOZAMBIQUENEPALNICARAGUAPAKISTAN PARAGUAYPERU ROMANIA RUSSIA RUSSIAN FED RWANDASEYCHELLESSIERRA LEONESOUTH KOREA SURINAMETAIWAN THE NETHERLANDS UKRAINE UZBEKISTANVENEZUELA VIETNAM WALLIS AND FUTUNA ISLANDSWEST INDIES ................
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