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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.

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

PINNO:

User:

Collected Amount

Service Charge

Transfer Amount

Exchange Rate

Receive Amount

Serial:315631

Deposite Type

Cash

THE ABOVE INFORMATION IS CORRECT AND I DELARE 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.

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

PINNO:

User:

Collected Amount

Service Charge

Transfer Amount

Exchange Rate

Receive Amount

Serial:315631

Deposite Type

Cash

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

JME Japan

SENDER INFORMATION

RECEIVER INFORMATION

PINNO:

JME Japan

SENDER INFORMATION

RECEIVER INFORMATION

PINNO: