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Last Name:*	Please provide your last name.
Street Address:*	Street address is mandatory field.
City:*	City is mandatory field.
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Zip Code:*	Zip is mandatory field.
State:*
Site Title:*	Site title is mandatory field.
Main URL:*

Phone Number:*	Phone number is mandatory field.
Email Address:*
Instant messaging service:
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Paxum

Paxum:

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Money Wire

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Wire transfer payments will be made in Euros using the USD/Euro exchange rate on the day payment is processed.
The minimum payment amount for Money Wire is $500. If you choose this option, your min payment amount will automatically be changed to $500.

ACH

ACH Money Transfer is for US residents only. Payments with this option are issued in USD

Cosmo

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Beneficiary

Beneficiary Name*	Please provide Beneficiary Name
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Street Address:*	Street address is mandatory field.
City:*	City is mandatory field.
Country:*	Country is mandatory field.
Zip Code:*	Zip is mandatory field.
State:*	State is mandatory field.

Beneficiary Bank

Bank Name:*	Bank Name Required
Street Address:*	Street address is mandatory field.
City:*	City is mandatory field.
Country:*	Country is mandatory field.
Zip Code:*	Zip is mandatory field.
State:*	State is mandatory field.
SWIFT ID*	Swift code required
ABA*	Acount bank number is required

Intermediary Bank

SWIFT ID
Bank Name
Bank Address
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Beneficiary

Beneficiary Name*
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Beneficiary Email:*
Beneficiary Document ID (SSN/DL/Tax ID) last 4 digits:*
Account Number:*
Account Type (Savings, Checking, etc.):*
Street Address:*	Street address is mandatory field.
City:*	City is mandatory field.
State:*
Zip Code:*	Zip is mandatory field.
Phone Number:*	Phone number is mandatory field.

Beneficiary Bank

Bank Name:*
Bank ABA routing number:*
Bank Address:*
Bank Address (City):*
Bank Address (State):*
Bank ZIP Code:*

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