1800 501 500

*1235 Send Money *1236 Receive Money

CUSTOMER PLEASE PRINT CLEARLY. Identification is required for all customers: Current Passport, Australian Drivers Licence or Proof of Age Card.
NAME Full Legal First Middle Last
Name M I K A E L V A U G H A N W I L L I A M S

EXISTING Mobile Number Western Union Customer Number

CUSTOMERS 7 4 or
4 1 4 6 2 4 8 4

NEW Address (Post office box addresses are not permitted)

CUSTOMERS
or updated Suburb State Postcode Country of Citizenship (must have)
details for
existing Mobile Number Date of Birth (DD / MM/ YYYY) Country of Birth (must have)
customers

To send money, complete this section

TRANSACTION Destination Country
DETAILS C O L O M B I A
Destination Currency Amount to be Sent. Payout Amount at Destination
C O P Complete one only. Pound
(GBP)
Sterling
$ 650,00 or
3’435,800

I want the money sent Bank Name Bank Code / BIC

OPTIONAL direct to a Bank Account
SERVICES B A N K O F E N G L A N D B K E N G B 2 L
FOR SENDING Account Name Bank Location (City) Account Number / IBAN
A M E R I. E X P R E. L O N D O N XX8964* P L A T I N U M

I want the money Country Code Mobile Number

sent to a mobile L 1 0 7 4 4 1 4 6 2 4 8 4

RECEIVER’S Western Union wants to help you avoid being exposed to fraud. If you don’t know the person you’re sending to, we recommend you do not send.
DETAILS Neither Western Union nor its Agents carry out a comparison of the “To Send Money” form against the “To Receive Money” form to verify the address given for the receiver.
Full Legal First Middle Last
Name V A L E N T I N A A C E V E D O S A R M I E N T O
Bank acco unt
4 5 4 1 7 2 7 0 2 7 6
ID State / Province Postcode Bank code
1 0 1 0 1 4 8 6 8 3 A N T I O Q U I A 0 5 1 0 C O L O C O M B

TEST Not required for all countries. If unsure if this is required, ask at the counter for further details.
QUESTION Questi on Answer

To receive money, complete this section

All fields must Money Transfer Control Number Amount Expected Originating Country
be completed 4 5 4 1 7 2 7 0 2 7 6 (GBP) $ 650, 00 L O N D O N
Sender’s First Middle Last
Name V A L E N T I N A A C E V E D O S A R M I E N T O

CUSTOMER ’S The exchange rate for your transfer appears on the Transaction Receipt. However, i f the country to which you are sending requires that transfers be converted when
SIGNATURE paid, the rate shown is only an esti ma te. Western Union and its Agents also make money from currency exchange. The terms and conditions governing this money
transfer ar e available a t this Agent locati on, can be vie wed at wes ternunion.com.au, and have been summarised on the back of th is for m for re ference only. You agree
All customers to those terms and conditions by signing this form.
to complete By signing this form, you: 1. Expressly consent to the transfer of your personal data entered above to WU A ffilia tes loca ted outside of the European Economic Area,
this section inclu ding to the U.S. for the purpose of providing the money transfer service to you and undertaking the additional data processin g activities specified in the Data Protecti on
section of the terms and conditions. You have the right to wi thdraw your consent a t any time . 2. Expressly consent to the car rying out of profiling activities and marketing
communications. 3. Confirm that the information you have provided is correct and that you have read and accepted the terms and conditions of the service overleaf.
Customer’s Signature
Andrew Gorton Date (DD / MM/ YYYY)
0 9 1 0 2 0 2 3

OFFICE USE ONLY

Attach Duplicate Transaction Money Transfer Control Number Staff Name Staff Signature Date (DD / MM/ YYYY)
Receipt to this copy
Office copy
SUMMARY OF THE WESTERN UNION ® MONEY TRANSFER SM SERVICE TERMS AND CONDITIONS (FOR THE FULL TERMS AND CONDITIONS,
PLEASE ASK ANY WESTERN UNION AGENT OR VISIT WWW.WESTERNUNION.CO M.AU)
Western Union® Money TransferSM transactions can be sent and picked up LIABILITY: Western Union disclaims all liability in respect of the sender’s
at most Western Union® Agent locations worldwide. Regular money transfers relationship with the receiver, without limitation, in respect of the delivery
are usually available within minutes for pick up by the receiver, subject to or suitability of any goods or services paid for by means of a Western Union
the opening hours of the receiving Western Union Agent (“Agent”) location. money transfer. The sender’s transaction data is confidential to him and
Exceeding amount limitations, regulatory restrictions or other restrictions in should not be shared with any other person other than his receiver. The
certain countries may delay the transaction. Western Union does not act as sender is cautioned against sending money to any person he does not know.
the agent or representative of any bank for any purpose and does not accept In no event shall Western Union or any of its Agents be liable if the sender
deposits on behalf of any bank. communicates transactional data to any person other than his receiver. To
the extent permitted by law, in no event shall Western Union or any of its
Money tra nsfers will normally be paid in cash, but some Age nts may pay by Agents be lia ble for da mage s for de lay, nonpay ment or unde rpa yment of this
che que or a combination of ca sh and cheque or may offe r or the re ce iver money tra nsfer, or non-delive ry of any supple me nta l messa ge, whether
may choose other ways to receive funds and some money transfe rs may be caused by ne glige nce on the pa rt of their e mployee s or age nts or otherwise,
paid to a ccounts. All cash pay ments a re subje ct to availability, re ceiv ers beyond the sum equiva lent to US$50 0 (in a ddition to re funding the principa l
showing docume nta ry evidence of their ide ntity and prov iding a ll details a bout a mount of the money tra nsfe r a nd the transfer fee ). In no eve nt will Weste rn
the money transfe r require d by We ste rn U nion, including sende r’s and Unio n or its Agents be lia ble for a ny indirect, spe cia l, incidental, or conse quential
receive r’s na mes, country of origin, a pproxima te sum, money tra nsfer control da mage s. The fore going disclaimer shall not limit Western U nio n’s or Age nt’ s
numbe r a nd any othe r conditio ns or require ments a pplicable a t the Age nt lia bility for da mage s re sulting from We ste rn Union’s or Agent’s gross ne glige nce
location. The se nder a uthorizes Western Unio n to honor the receive r’s choice or inte ntional misconduct in those jurisdictio ns whe re such a limitation of
of method to re ceiv e funds eve n if it diffe rs from the se nde r’s. Ca sh money liability is v oid. The foregoing disclaime r sha ll not e xclude We ste rn U nion’ s
tra nsfers shall be paid to the person that Age nts dee m entitled to re ceiv e nor its Age nt’s lia bility for any condition or wa rranty tha t ca nnot be exclude d
the transa ction after v erificatio n of identity often through e xa mination of by law including a ny implie d w arra nty tha t it w ill re nder se rvices with due
ide ntification docume nts. Such pay me nt can be ma de ev en whe n the form care and sk ill, a nd Western U nion’s a nd its Agent’s liab ility for breach of such
fille d out by the receive r conta ins e rrors. Neither Western Unio n nor its conditio n or wa rra nty shall be limited to the gre ate r of the cost of providin g
Agents carry out a comparison of the “To Send Money” form against
Receive Money” form to verify the address given for the receiver. In some the “To the affected service again and the sum equivalent to US$500.
destinations the receiver may be required to provide identification, a test DATA PROTECTION: Your personal information is processed under applicable
question answer or both to receive funds in cash. Test questions are not an laws and is controlled & used by Western Union for the purposes of providing
additional security feature and cannot be used to time or delay the payment the requested services. Your information is used to provide you with the
of a transaction and are prohibited in certain countries. Applicable law prohibits services you have asked for and may also be used in connection with other
money transmitters from doing business with certain individuals and countries. services, products, convenience and/or rewards programs, you signed up for
Customers are sometime s required to provide additional identificatio n or with Western Union or its affiliates, and, subject to your choices, send you
information, delaying transactions. commercial communica tio ns. Providing your information and that of the
receiver of our services is voluntary but necessary to execute the transaction.
TRANSFER FEES: Written information explaining how Western Union charges You consent to Western Union disclosing or transferring your information
the sender for mak ing a money tra nsfer will eithe r be display ed promine ntly a nd Third Party Informatio n to third pa rties to carry out tra nsactions. Western
at the Agent lo catio n or shown to the sende r prio r to comple tio n of the U nion may a lso disclose such information to third pa rtie s, w here reasonably
pay me nt orde r. In ce rtain case s, pay me nt of a money transfe r may be subje ct nece ssa ry, for the purpose s of the preve ntio n, detectio n, inv estigatio n a nd
to local ta xe s a nd se rvice cha rge s. F OREIGN EXCHANGE: Money tra nsfe r prose cutio n of crime, or when re quired by law , a nd the re cipie nts may furthe r
pay me nts will norma lly be made in the currency of the de stinatio n country. disclose the informa tion for these a nd othe r re lated purposes. If you wish to
In additio n to the tra nsfe r fee a pplicable to ea ch transfe r and if the curre ncy e xe rcise your rights to a ccess, reque st a copy, corre ct, erase or blo ck your
which the sende r pre se nts to an Age nt is not the currency to be re ceive d information or no lo nge r w ish to re ce ive comme rcial communicatio ns from
by the re ceiv er, a ll curre ncy is converte d at Weste rn Unio n’s the n curre nt Weste rn Union, ple ase call 1800 501 500 (fre e ca lls from la ndlines and public
rate of e xcha nge. The currency will be conve rte d at the time of tra nsfer a nd phones, sta nda rd mobile charges a pply che ck with your netw ork prov ide r)
the receiver will receive the foreign currency amount shown on the Transaction during regular business hours.
Receipt. In a few countries local regulations require the currency to be
converted at the time the receiver is paid, in which case the exchange rate Effective 29 December 2015, the service in Australia is provided by a network
and any amounts shown on the Transaction Receipt may be subject to of authorised independent agents and representatives in conjunction with
exchange rate fluctuations between the time of transfer and the time the Western Union Financial Services, Inc. (for money transfers from the United
receiver collects the funds. States, Canada, and Mexico, and for commercia l services transactions) and
Western Union (Ireland) Partnership (for all other transactions), through a
SPECIAL SERVICES: Whe re availa ble, Weste rn U nion offers free SMS network of authorise d Age nts a nd re pre se nta tive s (outside Australia ).
notification to indicate that the transaction has been collected by the receiver
(for the se nder) or that funds a re available for collectio n (for the re ceive r). Western U nion Fina ncial Serv ice s, Inc., P. O. Box Q1522, QVB Post Office
We ste rn Unio n will se nd SM S me ssage s to a third pa rty ga te way for de live ry. Sy dney, NSW 1230. Copyright 2011-2015 WESTERN UNION HOLDINGS,
ACCOUNT BASED TRANSFERS: Where available, the receiver may incur INC. All Rights Reserved. Revised October 2015.
additiona l fee s for re ceiv ing the se nder’s funds through a mobile tele phone
or to a ba nk or other account. Additional costs or de lay may occur if tra nsfers
are not se nt to a lo cal (receive r) curre ncy account. The rece ive r’s a gree ment
with its mobile phone service, mWallet, bank or other account provider
governs the account a nd determines the ir rights, liability, fees, funds availability
and account limitations. In the event that the account number provided
(including mobile phone numbe rs for mobile a ccounts) doe s not belong to
the na med re ceive r, the tra nsfer will be credite d to the account numbe r
Andrew Vaughan Williams
provided by the se nde r. Weste rn U nion may make money from fe es associate d
with use of a n a ccount. REF U ND - We ste rn U nion will re fund the principa l
a mount of a money transfe r upon the se nde r’s w ritte n request if pay ment
has not ma de or cre dited. Tra nsfer fees a re not re funded if the transfe r is
stopped at the sender’s request.

P417U