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WESTERN UNION Gold card NUMBER I would like to sign-up to the Gold card
If you have a Gold card, please only fill gold shaded areas e.g.: Example
SENDER
First / Given name (s)
Last / Family name
Address Postcode
BIC/SWIFT/IFSC
Get a free SMS when your money has been picked up Please keep me up to date by Email with the latest offers and news from Western Union and partners
Mobile Number (optional) Email (optional)
You can change your marketing preferences at any time
RECEIVER
First / Given name (s)
Last / Family name
Question Answer
DO NOT provide a test question, unless you are asked to do so by the agent
IMPORTANT NOTICE
The terms and conditions on which the service is provided are set out on the reverse of
this form. You are advised to read these terms and conditions, especially those restricting CUSTOMER SIGNATURE * DO NOT DIVULGE * By signing this form I confirm that the
information I have provided is correct and
liability and data protection, before signing this form. In addition to the transfer fee, ANY DETAILS OF that I have read and accepted the terms
Western Union and its agents also make money from the exchange of currencies. Please THIS TRANSFER
see further important information regarding currency exchange and legal restrictions and conditions of service overleaf and
that may delay the transaction set forth on the back of this form. Protect yourself from TO A THIRD PARTY. the loyalty program terms if applicable.
consumer fraud. Be careful when a stranger asks you to send money.
WESTERN UNION Gold card NUMBER I would like to sign-up to the Gold card
If you have a Gold card, please only fill gold shaded areas e.g.: Example
SENDER
First / Given name (s)
R
Last / Family name
E
Address Postcode
M
Service type In Minutes 2 Day/Next Day Mobile Money Transfer Direct to Bank
(Subject to the opening hours (where available) (where available) (where available)
Ask agent for details of the receiving location)
O
Mobile Money Transfer (where available) Direct to Bank (where available)
Mobile Number Bank Name
T
Account Number / IBAN
Bank Code
S
BIC/SWIFT/IFSC
Get a free SMS when your money has been picked up Please keep me up to date by Email with the latest offers and news from Western Union and partners
U
Mobile Number (optional) Email (optional)
You can change your marketing preferences at any time
C
Telephone the receiver (Tel No) Message to be sent
Home cheque delivery
Fill in receivers address
RECEIVER
First / Given name (s)
Last / Family name
Question Answer
DO NOT provide a test question, unless you are asked to do so by the agent
IMPORTANT NOTICE
The terms and conditions on which the service is provided are set out on the reverse of
this form. You are advised to read these terms and conditions, especially those restricting CUSTOMER SIGNATURE * DO NOT DIVULGE * By signing this form I confirm that the
information I have provided is correct and
liability and data protection, before signing this form. In addition to the transfer fee, ANY DETAILS OF that I have read and accepted the terms
Western Union and its agents also make money from the exchange of currencies. Please THIS TRANSFER
see further important information regarding currency exchange and legal restrictions and conditions of service overleaf and
that may delay the transaction set forth on the back of this form. Protect yourself from TO A THIRD PARTY. the loyalty program terms if applicable.
consumer fraud. Be careful when a stranger asks you to send money.
Copyright © 2013 WESTERN UNION HOLDINGS, INC. All Rights Reserved. Revised April 2013