CIS VISANET _____Nombre de la Empresa o Persona Física_______

1 Company Name:

2 Company Reg. Address:

3 Company Reg. Number:

4 Represented by:

5 Title:

6 Nationality:

7 Passport detail (N°):

8 Date of Issue:

9 Date of Expiry:

10 Place of Issue (Country):

11 Bank Name:

12 Bank Address:

13 Swuift Code/BIC:

14 Account Name:

15 Account Number:

16 Card Number:

17 Bank ID:

18 Branch ID:

19 IAT (VISANET) Number:

20 ICA:

21 Card Represented by:

22 AUTHORIZED LIMIT TO
RECEIVE MONEY

1
PASSPORT COPY

2
COMMERCIAL REGISTER’S COPY

3
VISA NET CARD AND BANK RECEIPT