MONEY TRANSFER REQUEST AND NOTICE/Application Date/

Receipt Number←FAX(For Our Use Only)

Please specify the same spelling with your identification card as it is important when identifying you.
「＊」Items: Please fill in these items only when there is any change in the registration information.
(Kana)

Member ID

Ｍ－*Telephone No.:－Name＠

03 - 5338 - 8689

Applicant*E-mail Address□Japanese*E-mail Language―

Postal CodePrefecture□Korean□English

City/District/Town*Address （Please specify the name of building, floor and room number correctly.)Occupation□Company or Organization officer □Government worker □Self Employed □Part-time job,Temporary staff, Contract employee(Non-members only) □Company employee,Organization staff □Housewife □Student □Inoccupation □Other()
My Number(Non-members only)(For confirmation of the number based on the law on foreign remittances.)

Total AmountYen* The amount after deducting the transfer fee from the transferred amount shall be the transfer amount of the customer.
* Please note that the deposit of transfer funds in the name other than the customer shall be refused.

To be deposited on (date/month)or expected to be deposited on (date/month).
□Account Holder: Sumitomo Mitsui Banking Corporation / Akasaka Branch / Ordinary / Account No. 9159880 Digitel Co., Ltd.
□Account Holder: Post Bank/ Code 10060 / No. 72543311 Digitel Co., Ltd.
□Cash
□Plan A (It is the money transfer service for Korea and the funds are deposited into the receiver's account in Korean won.)
Money Transfer Plan
□Plan B (It is the money transfer service provided by MoneyGram. Funds can be received at MoneyGram’s retail locations or its network of agents.
Do you agree if we send the certificate of receipt by e-mail?
□Yes □No（At our counter)

Money Trasnfer Method

Plan Ａ: If you want to register the receiver, please specify the registered number and receiver's name.
Plan Ｂ: If you want to register the bank account, receiver's bank account, please specify the RRN (Receiver Registration Number).

ReceiverInformation【Receiver No.
□Living Expenses

Purpose ofMoney Transfer□Educational or Medical Expenses□Redemption (□Over 1 Year □Within 1 Year)

Receiver（Roman Alphabet)□Monthly Rent

□Product Purchase（Product Name:□Others（Name(Required ifnotregistered)
Address(Required ifnotregistered)

Receiver'sName】□Insurance (□Life Insurance □Indemnity Insurance)
Place of Origin:□Savings

Place of Shipment:)）(Roman Alphabet)
Receiving Country(Roman Alphabet)

Date of Birth//(yyyy/mm/dd)

Mode of Payment－Telephone No.

－RelationshipBank

Account No.

Confirmation of the substantial controlling person in the case of a corporation(more than 50% of the voting rights holder, or, in the case of other than the left, the individual or corporation holding more than 25% of the voting rights)
First effectiveFullAddress :□Not applicable□Applicable
ruler
name :
Second effective FullAddress :rulername :
I hereby agree to Terms and Conditions and the important matters for international money transfer service, and pledge that this money transfer is not applicable to Article 17 (Exclusion of Antisocial Forces) ofthe Terms and Conditions of International Money Transfer Service.
I notify the above in accordance with the provisions of Article 3 of the "International Money Transfer Report Submission Act for Promoting the Securement of Proper Taxation of Internal Tax.
I hereby confirm that this money transfer is not contradictory to the regulations related to Iran and North Korea defined in the "Foreign Exchange and Foreign Trade Law.
By signing below, you confirm that you have read and understood the Fraud Warnings at the bottom of this form, that you are not sending this money transfer for any of the purposes listed in the Fraud Warnings
on this form, and that you are not doing anything that you are warned not to do at the bottom of this form.

Please sign after checking the above details.

Signature:

For Our Use Only
Confirmation of Receipt

Confirmation of Deposit(Time：)／：Money Transfer(Amount Transferred)

／：

Yen

Expected Time ofReceipt

Inspection／□Verification of My Number □Destruction of My Number documents (in the case of non-face-to-face transactions)Remarks
FRAUD WARNINGS! STOP!
Please read the questions below carefully to help us protect you from becoming a victim of fraud or a scam. Are you sending money:• to someone you don’t know or whose identity you cannot verify?
• to prove to someone that you have the available funds to buy a car, other goods, or to rent a property? Are you being asked by any 3rd party to provide any details about this transaction
in part or in full by phone, email, fax or website?
• to buy a product/ service or a pet via the internet or anywhere else in response to any offer that sounds very cheap in comparison to their expected price or looks “too good to be true”?
• to claim lottery or prize winnings, inheritance, for a “guaranteed” credit card, loan offer, refund of bank charges or attractive investments?
• in response to an internet offer, letter or phone call that asks you to send money for a “job offer” or “mystery shopping” or a “charity”?
• to someone at home or overseas who claims to be your relative needing cash for an “emergency” and you are unable to verify independently if the caller and the claims are genuine?
• to someone you met in an on-line chat room or dating web site for financial assistance? Examples: airplane ticket, medical bills, helping a relative, cashing a check, investing in a business deal, etc.
• to buy goods and services from someone who specifically recommends money transfer through MoneyGram as the preferred mode of payment?
IF you answered YES to any of these questions, DO NOT SEND the money transfer - someone may be trying to STEAL YOUR MONEY. Remember neither digitel and MoneyGram nor its agents will be liable
if you ignore the fraud warnings above and still choose to send money for any of the reasons listed above.

Digitel Co., Ltd.
Registration No. (Chief Financial Officer of Kanto Province No.00023)
JENET Co., Ltd.
Phone number：03-5332-7324
FAX:03-5338-8689
E-mail: remit@jenet.co.jp