REMITTANCE APPLICATION FORM

NEW REMITTER

IREMIT USE ONLY

Date (Petsa):

Agent's Code/Foreign Office

RIF No.:

OLD REMITTER

REMITTER INFORMATION
Contact Number (Telephone or/and Cellphone No.)

Name (Pangalan)
SURNAME

FIRST NAME

Present Address (Kasalukuyang Tirahan)

MIDDLE NAME

Permanent Address (Permanenteng Tirahan)

Office Address (Lugar ng Trabaho)

ID Number:

Type of ID/s Presented:

DOOR-TO-DOOR

BENEFICIARY INFORMATION
Primary Beneficiary

Alternate Beneficiary

Relationship to Sender

Relationship to Sender

Home Address (Tirahan)

BANK-TO-BANK
Bank Name
ZIP Code

Landmark

Branch Name
Account Number

National ID Number (if applicable)

Contact Number (Telephone or/and Cellphone Number)

NOTIFY & PAY

Paying Station

Password

VISA CARD
Card Number

REMITTANCE AMOUNT

OTHERS

Amount and currency in words and figures.

Message (For Door-to-Door only)

Purpose of Remittance
Service Fee

Total

Rate

Peso Equivalent

White: iRemit Copy

Yellow: Customer Copy

Pink: Foreign Office/Agent Copy

iRemit Processing Officer/Staff

Signature over Printed Name

Remitter's Signature Over Printed Name

RAF 101608