Electronic Payment Information Form - The Denver Gold Group, Inc.

Please reduce transaction costs by using a US Dollar account.

Wire Transfer & ACH Information

Representative Name *

First

*

Last

Email *

Bank Payment System

SWIFT

CHIPS

FedWire

IBAN

Bank Payment ID (e.g. SWIFT code)

Bank Account Currency

Name(s) on Bank Account *

Bank Name *

Bank Account Number

Routing Number (only for USA banks)

Bank Address

Bank Address

Bank Address

Bank Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Does your bank require the use of an intermediary bank to receive USD funds electronically?

Yes

No

Bank ID Type (If Bank ID type is ABA, then the recipient Bank ID must be for a bank authorized for the receipt of electronic wires.)

Bank ID

Intermediary Account (if appropriate enter the IBAN)

Bank Name

Bank Address

Bank Address

Bank Address

Bank Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Date *