Threadneedle Street, London, EC2R 8AH -United Kingdom
Direct Line: +447443187089
Form Number: PRA893923
MCC APPLICATION TITLE FORM A Kindly provide us with the following information, as required to apply for the Money Clearance Certificate (MCC) ; Section (I) Personal Information Full Name………………………………………………………………………………………………………….……………………………………… Address…………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………………. Nationality…………………………………………… Sex……………………………..…………… Age ………………………………………… Occupation……………………………………………………………………………………………………………………………………………….. Home phone…………………………………………………………… Mobile phone…………………………………………………………. E-mail address…………………………………………………..……..……………… Fax……………………………….……………………….. Section (II) Fund information Amount won : ........…………………...................................................................................………………… How do you want to receive your funds?
Bank Transfer (TT) Certified Bank Draft/Cheque I declare that to the best of my knowledge, all particulars supplied by me are correct. I am aware that any false statements will lead to my application for fund release being rejected and may render me liable for prosecution for perjury.
Date…………………………………………………. Signature………………………………………………….
NOTE: WE WILL NOT PROCESS ANY APPLICATIONS SUBMITTED WITHOUT THE REQUESTED ISSUANCE FEE.