Remittance Membership Registration with Declaration/KYC Record
外国送金事前登録書兼告知書/本人確認記録

Name:

REMITTER ’S
INFORMATION
送金依頼人
ADDRESS IN JAPAN:
登録住所:

Birthdate:

ご依頼人名
Last Name 姓First Name 名

Middle Name (Write in full)(Please fill out and print using CAPITAL LETTERS) 「必ず大文字でご記入下さい. 日本名の場合はローマ字でご記入下さい。」

Contact No.

-Year 年 Month 月 Date 日

生年月日

連絡先 :

Gender:
性別

MaleFemale

男女

OCCUPATION 職業:

個人番号

携帯電話/Landline
自宅電話

Employee ・会社員

Self Employed ・自営業

Part time/Contractual ・バイト/契約社員
Others, specify ・その他：明記して下さい ____________________

Individual My Number: 12 digits • Corporate Number 法人番号: 13 digits

Salary Income ・給与等

MobileE-mail Address ﾒｰﾙｱﾄﾞﾚｽ:Nationality:
国籍

MY NUMBER:

SOURCE OF FUNDS 金源:

Registration No. 00011
Director General of Kanto Local
Finance Bureau Member ofJapan Payment Service Association (JPSA)

Business Income ・事業所得

Others, specify ・その他：明記して下さい___________________
Beneficiary Contact No.
受取先 連絡先BENEFICIARY INFORMATION • 受取人情報

Beneficiary Name:
受取先名First Name 名

Last Name 姓Middle Name

Date of Birth (mm/dd/yy) optional
生年月日 (月/日/年）

Beneficiary Address (City, Country):
受取人のご住所Purpose of Remittance(select one):送金目的（一つお選びください）

Mode ofPayment:
受取方法☐ Family Support/Living Expenses 家族支援 /生活費
☐ Savings 預金☐ Gift ギフト☐ Purchase of Property 不動産購入☐ Loan Payment ローンの支払☐ Social Insurance Payment 社会保険料の支払い☐ Business Expense 事業費☐ Others, specify その他: 明記して下さい:___________________☐ Payment of Import/Goods/Trade
輸入品/製品/貿易品の支払

Name of Merchandise 商品名：_________________________
Place of Origin 原産地：_______________________________
Port of Shipment 積荷港：_____________________________Cash Pickup • 現金受取
☐M-Lhuillier/LBC/Palawan

Credit to Account • 銀行口座受取___ PHP / ___ JPY / ___ USD
Account Currency 口座通貨

☐Cebuana Lhuillier☐ AUB ☐ BPI ☐ RCBC ☐BankCom☐BPI ☐AUB ☐RCBC ☐BDO ☐PNB ☐Metrobank☐BankCom ☐ Others その他: ____________________________

Mobile Wallet • モバイルウオレット☐GCASH (Mobile No.): ___________________________☐Maya (Mobile No.): ___________________________
Door to Door • 宅配 ☐ Yen to Yen ☐ Yen to Peso

For Nepal
Remittance only:

Relationship 続柄:Bills Payment

請求書支払 :

Account Number 口座番号:_____________________________☐SSS / ☐Pag-IBIG / ☐PhilHealth Number_____________________☐Others その他 ___________________________☐ Credit to Account • 銀行口座受取Bank Name/Account Number
銀行名/口座番号:___________________________________________________________☐ Cash Pickup • 現金受取

By signing below, I understand and agree on the following: (1) That I am authorizing SMTJ to register my personal information and, upon actual receipt of funds, to implement myremittances to the specific beneficiary registered. (2) That I am not a member of anti-social forces. (3) That the required items pursuant to Article 3 of “the Law on Reporting
Requirements on Cross Border Payments and Receipts for the Tax Law“ compliance are stated in this form. (4) That the information written on this application form is true and I hereby
confirm that the General Provisions and Privacy Policy and Customer Data Protection attached together with this form stated on the separate paper hereof will govern all remittances I
undertake through SMTJ. (5) That the remittance applied for by this application, and all subsequent remittances I will transact thru SMTJ, will not correspond to transactions with Iran,
Democratic People’s Republic of Korea, Russia, Belarus and other Japanese Government announced economic and assets freeze sanction list in accordance with the Foreign Exchangeand Trade law. In case of corporate beneficiary, that the beneficial owner of the corporate beneficiary does not have address in Democratic People’s Republic of Korea. 以下に署名することにより、私は以下の事項を理解し、同意します： (1)私は、SMTJが私の個人情報を登録し、実際に資金を受領した際に、登録された特定の受取人に送金を実行することを承認します。(2)私は、反社会的勢力ではないこと。(3)「国外送金等調書法」第3条に基づく必要事項が本様式に記載されていること。(4)本申込書に記載された内容が事実であり、本申込書に添付された重要事項の通知、プライバシー・ポリシー及び顧客データ保護規定が、私がSMTJを通じて行う全ての送金に適用されることを確認します。(5)本申込書により申請する送金、及びその後私がSMTJを通じて行う全ての送金は、イラン、朝鮮民主主義人民共和国、ロシア、ベラルーシ、その他外為法に基づき日本政府が公表した経済・資産凍結制裁リストに該当しないこと。法人が受取人の場合、当該法人の実質的所有者が朝鮮民主主義人民共和国に住所を有していないこと。
I certify that all information provided herein are accurate.
本用紙に記入した事項は全て正確であると証します。
__________________________________________

SIGNATURE ご署名___________________________

Date日付REQUIRED
DOCUMENTS
要件な書類

1. Valid I.D.(front and back side) ・有効な ID(表面と裏面)

2. Acceptable My Number Document・個人番号の証明

For FOREIGN NATIONAL: RESIDENCE CARD (RC)
非日本国籍者:在留カード

INDIVIDUAL CARD • マイナンバーカード
NOTIFICATION CARD • 通知カード *For JAPANESE NATIONAL: GOVERNMENT ISSUED ID
日本人: 政府発行ＩＤRESIDENCE CERTIFICATE • 個人番号記載された住民票** should have the same address as RC/ID

SMTJ USE ONLY (SMTJ使 用 欄 )IndividualCard

MY NUMBER
Proof Presented

Notification
Card

Residence
Certificate

Confirmed byand Date:

RMR Form Received by and Date :KYC BY FACE TO FACE
POST MAIL
SHOKAI BY:

REMITTANCE MEMBERSHIPNUMBER 会員番号 :SMTJ Branch/Agent Code:KYC and COMPLIANCE

Pending
Registration

RMR Encoded by / date:

RMC Issued by / date:

Final KYC Checked by / date:

RMC Mailed by / date:

Final RMR Scanned by / date:

Noted by and Date:
Reason:FASTER AND MORE CONVENIENTDOWNLOAD SPEED JAPAN FROM APP STORE

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FOR ADDITIONAL BENEFICIARY
OR INQUIRIES YOU MAY CONTACT US
Speed Money Transfer Japan K.K. (SMTJ)
9F Kinshicho City Building,2-13-4 Kotobashi Sumida-ku,
Tokyo 130-0022
Tel. (03) 6869-8555
Fax: (03) 3635-8625
VIBER App: +81 80-4143-9494
LINE App: +81 80-3508-8555
SMS Only: 080-3750-6268
Facebook: SPEED SMTJ
URL: https://www.smtj.co.jp

RMR form revised 2024.04.09