10/7/2017 member/general.company | member/general.

default_title

RECIBO
DOCUMENTO DE QUITAO

RECEIPT
PAY DIAMOND QUITTANCE DOCUMENT
Nmero scal / Fiscal Number:
Suite 3601, Two Exchange Square 8 Connaught Place, Central - Hong *Data Pedido de Saque / Date withdraw request:
Kong,,
/ _____________________________________________
Tel.:

*Login:___________________________________

*ID Saque: 93307

*ID Transao: 76203881

*USD $:___________________________________

* Nome Completo / Full Name:_____________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

* Morada / Address :
_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

* Importncia / Amount :
___________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________
(Escrito por extenso / Write out)

Assinatura Recebida a Importncia Supra

Signature Received the Above Amount

_____________________________________________________________ _______/_______/_______

Declaro para os devidos ns que para esse recibo car vinculado validao, a comprovao da transferncia bancria ser realizada
na minha conta conforme dados indicados abaixo:

I declare to the proper purposes for which this receipt is bound to validation, proof of bank transfer will be held in my account as
reported below:

* Conta Nmero / Account Number :

__________________________________________________________________________________________________________________________________________________________

* Agncia Nmero / Agency Number :

__________________________________________________________________________________________________________________________________________________________

* Nome do Banco / Name of Bank :

__________________________________________________________________________________________________________________________________________________________

* Codigo SWIFT/BIC / SWIFT Code / BIC :

__________________________________________________________________________________________________________________________________________________________

* IBAN/ABA / IBAN / ABA :

__________________________________________________________________________________________________________________________________________________________

* Nome Favorecido / Grantee Name :

__________________________________________________________________________________________________________________________________________________________

* Morada/Endereo / Address :
__________________________________________________________________________________________________________________________________________________________

* Cidade / City :
__________________________________________________________________________________________________________________________________________________________

* Pas / Country :
__________________________________________________________________________________________________________________________________________________________

* Campos com preenchimento obrigatrios / Fields required to ll

https://member.paydiamond.com/withdraw/receipt/print/76203881 1/2
10/7/2017 member/general.company | member/general.default_title

https://member.paydiamond.com/withdraw/receipt/print/76203881 2/2