Agent Information

Agent Name:*

Personal Information

First Name:*

Middle Name:

Last Name:*

Country:*

Zip Code:*

State:*

City/Ward:*

Area:* <%----%>

Additional Address:*

Gender:*

Native Country:*

Date of Birth:*

E-Mail ID:

Telephone No.:

Mobile No.:

Visa Status*

Employment Business Type:

Name of Employer:

SSN No:

Occupation:*

Source of Fund:*

Monthly Income: JPY 0 - JPY170,000 JPY170,000 - JPY340,000 JPY340,000 - JPY680,000 JPY680,000 - JPY1,300,000 Above JPY1,300,000

Security Information

Verification Id Type:*

Verification Type No.:*

Issue Date:*

Valid Date:*

Remitance Allowed:*

Online Login Allowed:*

Mobile Login Allowed:*

Additional Address Verification Document Collected (Mandatory for NON-FACE TO FACE customers):

Customer Registation Remarks:

Beneficiary Information:

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Country:*

Beneficiary Type:*

First Name:*

Middle Name:

Last Name:*

Native Country :*

Beneficiary Address:*

Beneficiary City:

Contact No:

Mobile No.: *

Id Type:

Id Number:

Place of Issue:

Relationship To Beneficiary:

Description of other relationship:

Transaction Information

Purpose of Remitance:

Payment Mode:*

Agent/Bank:

Beneficiary A/c #:

Branch:*

Beneficiary Registation Remarks:

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Document Information

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Agreement Information

私は、本依頼書に記載されているジャパンマネーエクスプレス株式会社の「海外送金利用規約」の内容に同意します。
私の依頼する送金は、北朝鮮及びイランとは関係無い取引であり、反社会勢力と一切の関りはありません。
私は「外内国の重要な公的な地位にある者」ではありません。
また申込書に表示された内容について間違いが無い事を確認した上で、JME送金サービスの利用を依頼します。

I understand and agree to the ”Terms and Conditions for Overseas Remittance” of Japan Money Express Co., Ltd. (JME).
I confirm that this remittance has nothing to do with North Korea or Iran. Also, I have no relation to any Anti-Social Forces or any engagement in illegal activities.
I am not Politically Exposed Persons(PEPs).
I confirm the information shown in this application to avail the remittance service is true and correct.

Customer Signature:

Sign above

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