REQUEST FOR WIRE TRANSFER REFUND (* = Mandatory fields)

GCI Account Information (Details of the account that the funds will be taken from)

*Account Number:

Ordering Customer (Your details)

*Name:  
*Street:
*Town / City:
*Telephone:
*Email:

Beneficiary Bank Information(Your bank details)

*Swift Code:
*Bank Name:
*Street: *Town/City: *Country:

Beneficiary Account Information(Your Bank account details)

Note: Third party payments are not permitted.
*Bank Account Number:
*IBAN:
*Account type:
*Bank Account Name:
Payment Details if any (Example - Invoice No 1234):

Identification Required

Please send the following documents:

	GCI use only
	On file	Date Recd
1. Passport, Identity Card or Driver’s License or other National Identity evidence bearing the photograph and signature
2. Copy of a utility bill or bank statement as proof of address

Additional

*Will you be closing your GCI account?
*Any comments on our service?

Authorised Customer Signature:
I / We accept that this request is governed by the General Terms & Conditions of GCI Financial LTD.

*Place & Date:

*Signature:

All information provided will of course be kept CONFIDENTIAL.
Please scan the document(s) to [email protected]