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Kanto Finance Bureau License

Number:0006

JME Japan

169-0073,Omori Building 4F(AB), Hyakunincho 1-10-07

Shinjuku-ku, Tokyo, japan

Tel:03-5475-3913, Fax:03-5475-3913

email:info@japanremit.com

Customer Copy

SENDER INFORMATION
Senders Name		Membership Card
Address
Nationality		Purpose
Date of birth		Mobile No.
Visa Status

RECEIVER INFORMATION
Payout Country
Receiver's Name		Payment Mode
Contact No		Correspondent
Address		Bank Name
Relationship		Branch
		Account No
Receive Amount NPR:

JME NO:

User:

Collected Amount

Service Charge

Transfer Amount

Exchange Rate

Receive Amount

Serial:

Deposit Type

THE ABOVE INFORMATION IS CORRECT AND I DECLARE THAT I READ TERMS AND CONDITIONS
Customer's Signature	..................................................	Operator:()	..................................................

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Kanto Finance Bureau License

Number:0006

JME Japan

169-0073,Omori Building 4F(AB), Hyakunincho 1-10-07

Shinjuku-ku, Tokyo, japan

Tel:03-5475-3913, Fax:03-5475-3913

email:info@japanremit.com

Office Copy

SENDER INFORMATION
Sender Name		Membership Card
Address
Nationality		Purpose
Date of birth		Mobile No.
Visa Status

RECEIVER INFORMATION
Payout Country
Receiver's Name		Payment Mode
Contact No		Correspondent
Address		Bank Name
Relationship		Branch
		Account No
Receive Amount NPR:

JME NO:

User:

Collected Amount

Service Charge

Transfer Amount

Exchange Rate

Receive Amount

Serial:

Deposit Type

THE ABOVE INFORMATION IS CORRECT AND I DECLARE THAT I READ TERMS AND CONDITIONS
Customer's Signature	..................................................	Operator:()	..................................................

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