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‘ô`°ü`e ∂`«`°T / π`jƒ`ë`J Ö`∏`W IQÉ`ª`à`°SGMONEY TRANSFER/DRAFT ISSUANCE APPLICATION

:ïjQÉàdG :´ôØdG

πjƒëàdG øe ¢Vô¨dG

ÖLƒÃ h Éæà«dƒÄ°ùeh/»à«dhDƒ°ùeh ÉæHÉ°ùM/»HÉ°ùM ≈∏Y √ÓYCG IQƒcòŸG á∏eÉ©ŸG AGôLEG AÉLôdG

.É¡H kɪ∏Y ÉfòNCG/äòNCGh ÉgÉfCGôb/É¡JCGôb »àdGh êPƒªædG Gòg ô¡X ≈∏Y áæ«ÑŸG •hô°ûdG

:QGó°UEG AÉLôdG

:™aódG á≤jôWAgainst Payment By:

:∞JÉ¡dG ºbQTel. No.:

:¿Gƒæ©dGAddress:

:áj’ƒdG:ó∏ÑdGCountry: State:

:áæjóŸG:…ójÈdG õeôdGZip Code: City:

:ó«Øà°ùŸG ∂æH:ó«Øà°ùŸG º°SGBeneficiary's Name: Beneficiary's Bank:

:ó«Øà°ùŸG ÜÉ°ùM ºbQBeneficiary's Account No.:

:∂æÑdG ¿GƒæYBank's Address:

:ó∏ÑdG:áæjóŸGCity: Country:

:…ôNBG π«°UÉØJOther Details:

Please effect the above transaction for my/our account and risk and subjectto the conditions on the reverse of this form which I/We have read and understood.

To be filled, if Remitter is other than the Account Holder.

:∫ƒëŸG º°SEGRemitter's Name:

:∫ƒëŸG ™«bƒJRemitter's Signature:

:∞JÉ¡dG ºbQTelephone No.:

Purpose of Remittance For Bank Use Only

Exchange Rate

Handling Charges

Total (AED)

Processor Verifier

Counter Value (AED)

:ájƒ¡dG ºbQh º°SE’GName & ID No.:

:QGó°UE’G ¿Éµeh ïjQÉJDate and Place of Issuance:

:¿Gƒæ©dGAddress:

Date:

Please Issue:

Branch:

¢ùµ∏àdÉH ¬dGƒMTelex TransferôNBG ÜÉ°ùM ¤EG ÜÉ°ùM øe πjƒ–Account to Account Transfer

:ºbQ ∂«°T ᣰSGƒHCheque No.::ºbQ ÜÉ°ùM ≈∏Y ó«≤dÉHDebit Account No.:

‘ô°üe ∂«°TDraftá«∏fi ¬dGƒMLocal Transfer

:á«MÉ«°S äɵ«°TTraveller's Cheques:

ID Type: Passport (á«JGQÉeEG) IOÉ«b á°üNQ :ájƒ¡dG ´ƒf∫GƒMC’G ábÉ£H/äGQÉeE’G ájƒ¡dG ábÉ£HôØ°S RGƒL Emirates ID / GCC ID Driving License (UAE)

Nationality: :á«°ùæ÷G:∞JÉ¡dG ºbQTelephone No.:

Details of Payment/Reference No.: _______________

Transfers may get rejected or delayed if above codes are not correctly tickedí«ë°üdG ¢Vô¨dG áfÉN øe Üô≤dÉH áë«ë°üdG IQÉ°TE’G ™°Vh ΩóY ∫ÉM ‘ ÉgÒNCÉJ hCG äÓjƒëàdG ¢†aQ ºàj ¿CG øµÁ

~~~~~~ :™LôŸG ºbQ / ™aódG π«°UÉØJ

SAL - Salary

ALW - Allowances

COP - Compensation

BON - Bonus

COM - Commission

EOS - End of Service

LAS - Leave Salary

TKT - Tickets

ACM - Agency Commission

OVT - Overtime

CCP - Corporate Card Payment

CRP - Credit Card Payments

CHC - Charitable Contributions

REM - Remittance

CBP - Cross Border Payments

INV - (MIS) Miscellaneous Payment with Invoice Details

RBC - (MIS) Miscellaneous Payment with Beneficiary Customer Reference

ROC - (MIS) Miscellaneous Payment with Ordering Customer Reference

ÖJGQ - SAL

ä’óH - ALW

¢†jƒ©J - COP

(¢üfƒH) ájƒæ°S ICÉaɵe - BONádƒªY - COM

áeóÿG ájÉ¡f - EOS

ájƒæ°ùdG IRÉLE’G ÖJGQ - LAS

ôØ°ùdG ôcGòJ - TKT ádÉcƒdG ádƒªY - ACM

‘É°VE’G âbƒdG - OVT

ácô°ûH á°UÉN ¿ÉªàFG ábÉ£H á©aO - CCP ¿ÉªàFG ábÉ£H äÉ©aO - CRP

ájÒN äÉYÈJ - CHCπjƒ– - REM

Ohó◊G ÈY äÉ©aO - CBP ÒJGƒa π«°UÉØJ ™e áYƒæàe äÉ©aO (MIS) - INV

𫪩dG ™Lôe ™e áYƒæàe äÉ©aO (MIS) - RBCó«Øà°ùŸG

𫪩dG ™Lôe ™e áYƒæàe äÉ©aO (MIS) - ROCÖ∏£dG Qó°üe

Currency Amount

Amount in words

May

20

13(E

)

Currency Amount

Amount in words

≠∏ÑŸG

±ôMC’ÉH ≠∏ÑŸG

á∏ª©dG

Exchange Rate

Handling Charges

Total (AED)

Counter Value (AED)

.ÜÉ°ù◊G ÖMÉ°U ÒZ ∫ƒëŸG ¿Éc GPEG Aõ÷G Gòg CÉÑ©j

§≤a ∂æÑdG ΩGóîà°SE’

(»JGQÉeEG ºgQO) á∏HÉ≤ŸG ᪫≤dG±ô°üdG ô©°S

ádhÉæe ∞«dɵJ

(»JGQÉeEG ºgQO) ‹ÉªLE’G

Samba Financial Group, P.O. Box 6038, Umm Suqeim 2, Jumeirah Beach Road, Dubai, United Arab Emirates, Tel: +971 4 709 1111, Fax: +971 4 709 1122, www.samba.ae

www.samba.ae ,+971 4 709 1122 :¢ùcÉa ,+971 4 709 1111 :∞JÉg ,IóëàŸG á«Hô©dG äGQÉe’G »HO ,IÒª÷G ≥jôW ,2 º«≤°S ΩG ,6038 Ü.¢U :»HO ´ôa ,á`«`dÉ`ŸG É`ÑeÉ`°S á`Yƒ`ª`é`e

:IBAN ºbQIBAN No.:

:IBAN ºbQIBAN No.:

Remittance Details ó«Øà°ùŸG πjƒëàdG π«°UÉØJ

I/we have received and understood the Bank’s Conditions Governing the Transfer of Funds and expressly agree and accept to be bound by them whether set out in English and/or Arabic.

ájó≤ædG äÓjƒëà∏d ᪶æŸG •hô°ûdG

ÜÉ°ù◊G ÖMÉ°U øe É¡ª∏à°ùj »àdG ≠dÉÑŸG ∫ƒëj ¿CG √ôjó≤J Ö°ùM ∂æÑ∏d ≥ëj ¬fEÉa ,ÜÉ°ù◊G á∏ªY ±ÓN á∏ª©H ≠dÉÑe ∂æÑdG º∏à°SG GPEG ,IOófih áëjô°U IQƒ°üHh É«£N ∂dP ±ÓN ≈∏Y ¥ÉØJ’G ºàj ⁄ Ée -1

.Éeõ∏eh É«FÉ¡f πjƒëàdG Gòg πãe AGôLEÉH »£ÿG ∂æÑdG ¿É«H ¿ƒµjh .≠dÉÑŸG ∂∏J ΩÓà°SG Ωƒ«d ‹ÉàdG πª©dG Ωƒj øY ôNCÉàj ’ óYƒe ‘ ∂æÑdG ‘ óFÉ°ùdG ™«ÑdG ô©°ùH

á©aódG ≈∏Y ó«Øà°ùŸG π°üëj ⁄ Ée π«cƒdG hCG π°SGôŸG ∂æÑdG iód óFÉ°ùdG AGô°ûdG ô©°ùH QƒcòŸG ó∏ÑdG á∏ª©H ¿ƒµ«°S ó«Øà°ùª∏d ™aódG ¿EÉa ¬«dEG πjƒëàdG ºàj …òdG ó∏ÑdG á∏ªY øY áØ∏àfl πjƒëàdG á∏ªY âfÉc GPEG -2

.äóLh ¿EG á«æ©ŸG Ωƒ°SôdG ™aO óæY ™aódG ºàjh ™aódÉH Ωƒ≤j …òdG ¬∏«ch hCG ∂æÑdG π°SGôe ÚHh ó«Øà°ùŸG ÚH Ö«JôJ ÖLƒÃ iôNCG á∏ª©H

∫ÉM …CÉH ÚdƒÄ°ùe ¬«∏°SGôe hCG ∂æÑdG ¿ƒµj ’h ,ÜÉ°ù◊G ÖMÉ°U øY áHÉ«f iôNCG á∏ªY hCG π«cƒdG hCG π°SGôŸG QÉ«àNG ájôM ∂æÑ∏d ¿ƒµj πª©dG Gò¡H ¬eÉ«b óæYh ≠dÉÑŸG πjƒëàd ájOÉ«àY’G äGAGôLE’G ∂æÑdG ™Ñàj -3

¥É£f øY êQÉN ÖÑ°S …C’ hCG ácô°ûdG hCG áë∏°üŸG √ò¡d ™HÉJ ∞Xƒe …CG hCG ¥ôHh ójôH ácô°T hCG áë∏°üe ájCG ÖfÉL øe ójÈdG hCG ¥ÈdG ‘ π°üëj ÒNCÉJ hCG AÉ£NCG hCG ´É£≤fG hCG ¢ü≤f hCG ∞∏J øY ∫GƒMC’G øe

.º¡«ØXƒe ÖfÉL øe hCG »Yôa π«ch hCG π°SGôe …CG øe hCG äÓ°SGôe ájCÉH ≥∏©àj ɪ«a πªY øY ´ÉæàeG hCG πªY hCG Ò°ü≤J hCG ∫ɪgEG hCG AÉ£NCG ájCG øY ’ƒÄ°ùe ∂æÑdG ¿ƒµj ’h ,‹GƒàdG ≈∏Y ¬«∏°SGôe hCG ∂æÑdG IOGQEG

Qô≤j ᫵æH kÉØjQÉ°üe ¿CG ¬«∏Y ≥ØàŸG øeh ,π«cƒdG / π°SGôŸG πÑb øe ∂æÑdG ¤EG π©ØdÉH ó«YCG ób ádGƒ◊G ≠∏Ñe ¿ƒµjh ÜÉÑ°SC’G øe ÖÑ°S …C’ ó«Øà°ùª∏d É¡©aO ºàj ⁄ GPEG ’EG ¢ùµ∏àdG ä’GƒM ᪫b IOÉYEG ºàj ’ -4

hCG á«aô°üŸG äɵ«°ûdG AɨdEG Rƒéjh .π°SGôŸG ∂æÑdG πÑb øe ≠∏ÑŸG IOÉYEG ¤EG …ODƒj ɇ ¢UÉÿG êPƒªædG ≈∏Y á∏eÉc ÒZ hCG áÄWÉN äÉeƒ∏©e ¬FÉ£YEG ádÉM ‘ ÜÉ°ù◊G ÖMÉ°U øe π°üëà°S ÉgQGó≤e ∂æÑdG

¬«a ºàj …òdG Ωƒ«dG ïjQÉàH ∂æÑdG πÑb øe IOóëŸG á«ÑæLC’G äÓª©dG AGô°T QÉ©°SCG Ö°ùM ∫ƒëŸG ≠∏ÑŸG IOÉYEG ºàj ∫GƒMC’G ™«ªL ‘h ,™aódG AɨdEÉH π°SGôŸG øe Gó«cCÉJ ∂æÑdG ΩÓà°SG ∫ÉM ‘ ɡફb IOÉYEG

.AÓcƒdGh Ú∏°SGôŸGh ∂æÑdG ∞jQÉ°üe É°übÉf ,™aódG

hCG óæ°ùdG ∂dP øY CÉ°ûæJ ób äÉeGõàdG …CG ó°V ∂æÑdG ájɪ◊ ∂dPh ,∂æÑdG øe ’ƒÑ≤e ¿ƒµj ¢†jƒ©J óæ°S Ëó≤àH ó¡©àj ÜÉ°ù◊G ÖMÉ°U ¿EÉa , ‘ô°üŸG ∂«°ûdG hCG ‹ÉŸG óæ°ùdG ∞∏J hCG ábô°S ,¿Gó≤a ádÉM ‘ -5

.√ÓYCG QƒcòŸG ܃∏£ŸG ∂«°ûdG ᪫b IOÉYEG hCG πjóH ∂«°T QGó°UE’ ÜÉ°ù◊G ÖMÉ°U ¬H Ωó≤àj Ö∏W …CÉH ≥∏©àj ɪ«a ∂dòch ∞dÉàdG hCG ¥hô°ùŸG ,Oƒ≤ØŸG ∂«°ûdG

.∂æÑdG øe É«dBG ¬ªàN ” GPEG ’EG áeRÓdG •hô°û∏d É«aƒà°ùeh Éë«ë°U Gòg πjƒëàdG Ö∏W Èà©j ’ ,äɵ«°ûdG hCG ó≤ædG πHÉ≤e πjƒëàdG äÉÑ∏£d áÑ°ùædÉH -6

äɵ«°ûdG ó≤ØJ áeÉY áØ°üHh ,¬«∏Y ܃ë°ùŸG ∂æÑdG ôjó≤àd É≤ah OGó°ùdG ¿ƒµj ∂dP ó©H ,É¡«∏Y í°VƒŸG ïjQÉàdG øe Qƒ¡°T áKÓK ∫ÓN OGó°ù∏d ∂æÑdG øY IQOÉ°üdG á«aô°üŸG äɵ«°ûdG áaÉc Ëó≤J Öéj -7

.…OÓ«ŸG ˃≤à∏d É≤ah IóŸG Ö°ù–h ,ÉgQGó°UEG ïjQÉJ øe Qƒ¡°T á©°ùJ ó©H É¡à«MÓ°U á«aô°üŸG

.ó«Øà°ùŸG ÜÉ°ùM ‘ ≠∏ÑŸG ó«b óæY πjƒ– …CG äGóFÉY øe ¬«∏Y ܃ë°ùŸG hCG π°SGôŸG ∂æÑdG øe ¢VôØJ ∞jQÉ°üe …CG øY ∫ƒÄ°ùe ÒZ ∂æÑdG ¿CG ÜÉ°ù◊G ÖMÉ°U ∑Qój -8

äÉeƒ∏©ŸG áaÉc .ó«Øà°ùŸG IBAN ÜÉ°ùM ¢SÉ°SCG ≈∏Y ÉgóMh IóëàŸG á«Hô©dG äGQÉeE’G ‘ á∏eÉ©dG ∑ƒæÑdG ‘ äó≤Y »àdG äÉHÉ°ùë∏d ¿ÉªàF’G ôKCÉàj ±ƒ°S ,…õcôŸG ∂æÑdG äÉ¡«Lƒàd É≤ah ¬fCÉH º∏©dG òNCG ≈Lôj -9

.É¡eGóîà°SG ºàj ød iôNCG π«°UÉØJh ó«Øà°ùŸG º°SG πãe iôNC’G

Conditions Governing the Transfer of Funds

1. Unless otherwise expressly and specifically agreed in writing, if the Bank receives funds in a currency other than the currency of the Account, the Bank may at its discretion convert the funds received from the Account Owner at the Bank’s selling rate on the day such funds are received. The Bank’s statement in writing that it has effected such conversion shall be conclusive and binding.

2. Currency of transfer, if different from that of the country to which the remittance is made, shall be payable to the payee in the currency of the said country at the Bank’s correspondent’s or agent’s buying rates unless the payee by arrangement with the Bank’s paying correspondent or agent obtains payment in some other currency upon payment of charges (if any) connected therewith.

3. The Bank will take its customary steps for transfer of funds and in doing so, the Bank will be free on behalf of the Account Owner to make use of any correspondent, sub-agent or other currency. In no case will the Bank or its correspondents be liable for any mutilations, omissions, interruptions, errors or delays occurring in the wire, cable or mail or on the part of any postal and telegraph authority or any employee of such authority or company or through any cause beyond the control of the Bank or its correspondents respectively. The Bank shall be not liable for any error, neglect or defaults, act or omission of any correspondent, agent or sub-agent or of their employees.

4. Refund of telex transfers will not be possible except in cases where the payment has not been made to beneficiary for whatever reasons and funds are returned by the correspondent/agent. It is agreed that a charge (determined by the Bank) will be collected from the Account Owner if, owing to incorrect information on the application request, the money transfer is returned by the paying bank. Cancellation and refund of drafts will be possible only after the Bank receives confirmation of effective cancellation from the paying bank. Refund to purchase in either case will be made on the basis of the Bank’s buying rate on the day of refund less the expenses of the Bank, its correspondents and agents.

5. If the draft or manager’s Check is lost, stolen or destroyed, the applicant will provide the Bank with an indemnity bond acceptable to the Bank, protecting the Bank against liability with respect to the lost, stolen or destroyed draft/ manager’s Check in connection with any request the applicant may make for the issuance of a replacement Check or a refund of the amount of the above requested Check.

6. For transfer requests against cash or Checks, the application will be considered valid only when machine stamped by the Bank.

7. All bank drafts issued by the Bank must be presented for payment within 3 (three) months from the date appearing on their face. Thereafter, payment will be at the discretion of the drawee and at any event bank drafts will become invalid 9 (nine) months from the date of their issue. Time shall be calculated in accordance with Gregorian calendar.

8. The Account Owner understands that the Bank is not to be held responsible for any charges levied by correspondent or paying bank from the proceeds of my remittance when crediting beneficiary’s account.

9. Please be advised that, as per Central Bank guidelines, credit to accounts held in banks operating in UAE will be affected solely based on the beneficiary IBAN. All other information provided such as the beneficiary name and other details will not be used.