Withdrawal Information Forum In order to process your withdrawal as quickly as possible, please fill out this withdrawal forum with complete and clear information. Please sign and date the forum and email to [email protected] if this is a withdrawal from your managed account or to [email protected] if this is for a commission payment. Amount of Withdrawal & Currency: Is this a Withdrawal from a Managed Account …(YES or NO).. , or a Commission Payment…(YES or NO)… Who is the First Level Affiliate that it comes from: Account Holder Information Account Holders Name: ………………………………………………………………………………………….. Account Holders Email Address = username OR: ……………………………………………………………. Account Holders Address: House or Apartment Number:…………………………………………………………………………….. Street Name or Number: …………………………………………………………………………………. City: ……………………………………………………………………………………………………… State or Province: ………………………………………………………………………………………….. Country:………………………………………………. Postal Code:……………………………………… Bank Information Bank Name: ………………………………………………………. Bank Address: ……………………………………………………. Building or Room Number: …………………………………………………………………………………. Street Number: ………………………………………………………………………………………………. City: ………………………………………………………………………………………………………… State or Province: …………………………………………………………………………………………… Country: …………………………………………………….. Postal Code: ……………………………….. Account Information Bank Swift Code/Bank Identifier Code: ………………………………………………………………….. International Bank Account Number/Account Number:…………………………………………………. Routing Number: ………..Not available for the Netherlands or Belgium………………………………. Account Holders Signature: Date: