Threadneedle Street, London, EC2R 8AH -United Kingdom

Direct Line: +447443187089

Form Number: PRA893923

MCC APPLICATION TITLE FORM A

Kindly provide us with the following information, as required to apply for the Money Clearance
Certificate (MCC) ;

Section (I) Personal Information

Full Name………………………………………………………………………………………………………….………………………………………
Address……………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………….
Nationality…………………………………………… Sex……………………………..…………… Age …………………………………………
Occupation………………………………………………………………………………………………………………………………………………..
Home phone…………………………………………………………… Mobile phone………………………………………………………….
E-mail address…………………………………………………..……..……………… Fax……………………………….………………………..

Section (II) Fund information

Amount won : ........…………………...................................................................................…………………

How do you want to receive your funds?

Bank Transfer (TT) Certified Bank Draft/Cheque

I declare that to the best of my knowledge, all particulars supplied by me are correct. I am aware that
any false statements will lead to my application for fund release being rejected and may render me
liable for prosecution for perjury.

Date…………………………………………………. Signature………………………………………………….

NOTE: WE WILL NOT PROCESS ANY APPLICATIONS SUBMITTED WITHOUT THE REQUESTED
ISSUANCE FEE.
In any event that the applicant fails to receive his/her prize, the MCC issuance fee shall be refunded in
full.