324-326 REGENT STREET, LONDON W1B 3BL

UNITED KINGDOM
TEL: +44 207 060 9063

FAX: +44 703 940 1393

FORM #: ABXE-RK-L04594-3494/8854

TRANSFER APPLICATION FORM (PRIZE CLAIM ONLY)

PERSONAL DETAILS
NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
GENDER: _ _ _ _ _ DATE OF BIRTH: _ _ /_ _ /_ _ _ _ / PLACE OF BIRTH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CONTACT ADDRESS:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
CITY: _ _ _ _ _ _ _ _ _ _ _ _ STATE/PROVINCE: _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ COUNTRY _ _ _ _ _ _ _ _ _ _ _ _ _ _
ZIP: _ _ _ _ _ _ _ _ _ _ HOME PHONE NO.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ MOBILE/PAGER: _ _ __ _ _ _ _ _ _ _ _ _ _ _
FAX NO.: _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E-MAIL: _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

JOB CONTACT DETAILS

WORKPLACE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
JOB TITLE _ _ _ _ _ _ _ __ _ _ DEPARTMENT _ _ _ _ _ _ _ _ _ _ _ _ POSITION HELD: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
OFFICE ADDRESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
CITY: _ _ _ _ _ _ _ _ _ _ STATE/PROVINCE: _ _ _ _ _ _ _ _ _ _ _ _ COUNTRY _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _
WORK PHONE NO.: _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ FAX NO: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
WORK E-MAIL: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

FOR SELF EMPLOYED APPLICANTS ONLY

If you are self - employed, please state your occupation and specialization in the spaces provided below:
OCCUPATION: _ _ _ _ _ _ __ __ _ _ _ _ _ _ SPECIALIZATION: _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _

FAMILY AND MARITAL STATUS

Please study carefully and check all that apply

MARITAL STATUS: Single _ _ _ _ _ _ Separated _ _ _ __ _ _ Married _ _ __ _ _ _ Divorced _ _ _ _ _ _

NEXT OF KIN
NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
GENDER: _ _ _ _ _ DATE OF BIRTH: _ _ /_ _ /_ _ _ _ / PLACE OF BIRTH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CONTACT ADDRESS:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
CITY: _ _ _ _ _ _ _ _ _ _ _ _ STATE/PROVINCE: _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ COUNTRY _ _ _ _ _ _ _ _ _ _ _ _ _ _
ZIP: _ _ _ _ _ _ _ _ _ _ HOME PHONE NO.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ MOBILE/PAGER: _ _ __ _ _ _ _ _ _ _ _ _ _ _
FAX NO.: _ _ _ _ _ _ _ _ _ _ E-MAIL: _ _ _ _ _ _ _ _ _ _ _ _ SOCIAL SECURITY NO.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

TRANSFER FUND INFORMATION

TOTAL TRANSFER AMOUNT [INHERITANCE SUM] IN WORDS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
TOTAL TRANSFER AMOUNT [INHERITANCE SUM] IN FIGURES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_

Bank Account Details

NAME OF BANK: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __
BANK ADDRESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CITY: _ _ _ _ _ _ _ _ _ _ _ _ _
STATE/PROVINCE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ COUNTRY: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ACCOUNT NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SWIFT CODE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ACCOUNT NUMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ SORT CODE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PLEASE LEAVE THE ACCOUNT DETAILS FIELD BLANK IF YOU WISH TO HAVE A CERTIFIED INTERNATIONAL
BANK DRAFT MAILED TO YOU. THE DRAFT SHALL BE MAILED TO THE ADDRESS PROVIDED BY YOU IN SECTION
1. [PERSONAL DETAILS] ABOVE.

OTHER DOCUMENTS
Please indicate the documents that you have attached to this form. Fill the appropriate Spaces for any option.

International Passport _ _ _ _ _ _ _ _ _ _ _ _

Driver's License _ _ _ _ _ _ _ _ _ _ _ _ _ __

National Identity card _ _ _ _ _ _ _ _ _ _ _ _

Other Valid Identity Card _ _ _ _ _ _ _ _ _ _

(If applicable in your country)

AFFIRMATION
I, _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ hereby affirm that all the information submitted by
me in this form is true at the time of submission. I also accept any disciplinary action taken against me for falsifying,
misrepresentation or incorrect presentation of my identity.

_ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _
(Applicants Signature)
Application must be printed, completed and returned by Fax or as scanned e-mail attachment.