Blank Western Union Template

CUSTOMER NAME

PLEASE PRINT CLEARLY. Identification is required for all customers: Current Passport, Australian Drivers Licence or Proof of Age Card.

EXISTING CUSTOMERS

NEW CUSTOMERS

or updated details for existing customers

TRANSACTION DETAILS

OPTIONAL

SERVICES FOR SENDING

Destination Country

I want the money sent to a mobile

Country Code

Mobile Number

City / Suburb

State / Province

Postcode

Country

TEST QUESTION

Not required for all countries. If unsure if this is required, ask at the counter for further details.

All fields must be completed

CUSTOMER’S SIGNATURE

All customers to complete this section

The exchange rate for your transfer appears on the Transaction Receipt. However, if the country to which you are sending requires that transfers be converted when paid, the rate shown is only an estimate. Western Union and its Agents also make money from currency exchange. The terms and conditions governing this money transfer are available at this Agent location, can be viewed at westernunion.com.au, and have been summarised on the back of th is form for reference only. You agree to those terms and conditions by signing this form.

By signing this form, you: 1. Expressly consent to the transfer of your personal data entered above to WU Affiliates located ou tside of the European Economic Area, including to the U.S. for the purpose of providing the money transfer service to you and undertaking the additional data processing activities specified in the Data Protection section of the terms and conditions. You have the right to withdraw your consent at any time. 2. Expressly consent to the carrying out of profiling activities and marketing communications. 3. Confirm that the information you have provided is correct and that you have read and accepted the terms and conditions of the service overleaf.

Customer’s Signature

Date (DD/MM/YYYY)

Western Union® Money TransferSM transactions can be sent and picked up at most Western Union® Agent locations worldwide. Regular money transfers are usually available within minutes for pick up by the receiver, subject to the opening hours of the receiving Western Union Agent (“Agent”) location. Exceeding amount limitations, regulatory restrictions or other restrictions in certain countries may delay the transaction. Western Union does not act as the agent or representative of any bank for any purpose and does not accept deposits on behalf of any bank.

Money transfers will normally be paid in cash, but some Agents may pay by cheque or a combination of cash and cheque or may offer or the receiver may choose other ways to receive funds and some money transfers may be paid to accounts. All cash payments are subject to availability, receivers showing documentary evidence of their identity and providing all details about the money transfer required by Western Union, including sender’s and receiver’s names, country of origin, approximate sum, money transfer control number and any other conditions or requirements applicable at the Agent location. The sender authorizes Western Union to honor the receiver’s choice of method to receive funds even if it differs from the sender’s. Cash money transfers shall be paid to the person that Agents deem entitled to receive the transaction after verification of identity often through examination of identification documents. Such payment can be made even when the form filled out by the receiver contains errors. Neither Western Union nor its Agents carry out a comparison of the “To Send Money” form against the “To Receive Money” form to verify the address given for the receiver. In some destinations the receiver may be required to provide identification, a test question answer or both to receive funds in cash. Test questions are not an additional security feature and cannot be used to time or delay the payment of a transaction and are prohibited in certain countries. Applicable law prohibits money transmitters from doing business with certain individuals and countries. Customers are sometimes required to provide additional identification or information, delaying transactions.

TRANSFER FEES: Written information explaining how Western Union charges the sender for making a money transfer will either be displayed prominently at the Agent location or shown to the sender prior to completion of the payment order. In certain cases, payment of a money transfer may be subject to local taxes and service charges. FOREIGN EXCHANGE: Money transfer payments will normally be made in the currency of the destination country. In addition to the transfer fee applicable to each transfer and if the currency which the sender presents to an Agent is not the currency to be received by the receiver, all currency is converted at Western Union’s then current rate of exchange. The currency will be converted at the time of transfer and the receiver will receive the foreign currency amount shown on the Transaction Receipt. In a few countries local regulations require the currency to be converted at the time the receiver is paid, in which case the exchange rate and any amounts shown on the Transaction Receipt may be subject to exchange rate fluctuations between the time of transfer and the time the receiver collects the funds.

SPECIAL SERVICES: Where available, Western Union offers free SMS notification to indicate that the transaction has been collected by the receiver (for the sender) or that funds are available for collection (for the receiver). Western Union will send SMS messages to a third party gateway for delivery. ACCOUNT BASED TRANSFERS: Where available, the receiver may incur additional fees for receiving the sender’s funds through a mobile telephone or to a bank or other account. Additional costs or delay may occur if transfers are not sent to a local (receiver) currency account. The receiver’s agreement with its mobile phone service, mWallet, bank or other account provider governs the account and determines their rights, liability, fees, funds availability and account limitations. In the event that the account number provided (including mobile phone numbers for mobile accounts) does not belong to the named receiver, the transfer will be credited to the account number provided by the sender. Western Union may make money from fees associated with use of an account. REFUND - Western Union will refund the principal amount of a money transfer upon the sender’s written request if payment has not made or credited. Transfer fees are not refunded if the transfer is stopped at the sender’s request.

LIABILITY: Western Union disclaims all liability in respect of the sender’s relationship with the receiver, without limitation, in respect of the delivery or suitability of any goods or services paid for by means of a Western Union money transfer. The sender’s transaction data is confidential to him and should not be shared with any other person other than his receiver. The sender is cautioned against sending money to any person he does not know. In no event shall Western Union or any of its Agents be liable if the sender communicates transactional data to any person other than his receiver. To the extent permitted by law, in no event shall Western Union or any of its Agents be liable for damages for delay, nonpayment or underpayment of this money transfer, or non-delivery of any supplemental message, whether caused by negligence on the part of their employees or agents or otherwise, beyond the sum equivalent to US$500 (in addition to refunding the principal amount of the money transfer and the transfer fee). In no event will Western Union or its Agents be liable for any indirect, special, incidental, or consequential damages. The foregoing disclaimer shall not limit Western Union’s or Agent’s liability for damages resulting from Western Union’s or Agent’s gross negligence or intentional misconduct in those jurisdictions where such a limitation of liability is void. The foregoing disclaimer shall not exclude Western Union’s nor its Agent’s liability for any condition or warranty that cannot be excluded by law including any implied warranty that it will render services with due care and skill, and Western Union’s and its Agent’s liability for breach of such condition or warranty shall be limited to the greater of the cost of providing the affected service again and the sum equivalent to US$500.

DATA PROTECTION: Your personal information is processed under applicable laws and is controlled & used by Western Union for the purposes of providing the requested services. Your information is used to provide you with the services you have asked for and may also be used in connection with other services, products, convenience and/or rewards programs, you signed up for with Western Union or its affiliates, and, subject to your choices, send you commercial communications. Providing your information and that of the receiver of our services is voluntary but necessary to execute the transaction. You consent to Western Union disclosing or transferring your information and Third Party Information to third parties to carry out transactions. Western Union may also disclose such information to third parties, where reasonably necessary, for the purposes of the prevention, detection, investigation and prosecution of crime, or when required by law, and the recipients may further disclose the information for these and other related purposes. If you wish to exercise your rights to access, request a copy, correct, erase or block your information or no longer wish to receive commercial communications from Western Union, please call 1800 501 500 (free calls from landlines and public phones, standard mobile charges apply check with your network provider) during regular business hours.

Effective 29 December 2015, the service in Australia is provided by a network of authorised independent agents and representatives in conjunction with Western Union Financial Services, Inc. (for money transfers from the United States, Canada, and Mexico, and for commercial services transactions) and Western Union (Ireland) Partnership (for all other transactions), through a network of authorised Agents and representatives (outside Australia).

Western Union Financial Services, Inc., P.O. Box Q1522, QVB Post Office Sydney, NSW 1230. Copyright 2011-2015 WESTERN UNION HOLDINGS, INC. All Rights Reserved. Revised October 2015.

CUSTOMER NAME

PLEASE PRINT CLEARLY. Identification is required for all customers: Current Passport, Australian Drivers Licence or Proof of Age Card.

EXISTING CUSTOMERS

NEW CUSTOMERS

or updated details for existing customers

TRANSACTION DETAILS

OPTIONAL

SERVICES FOR SENDING

Destination Country

I want the money sent to a mobile

Country Code

Mobile Number

City / Suburb

State / Province

Postcode

Country

TEST QUESTION

Not required for all countries. If unsure if this is required, ask at the counter for further details.

All fields must be completed

CUSTOMER’S SIGNATURE

All customers to complete this section

The exchange rate for your transfer appears on the Transaction Receipt. However, if the country to which you are sending requires that transfers be converted when paid, the rate shown is only an estimate. Western Union and its Agents also make money from currency exchange. The terms and conditions governing this money transfer are available at this Agent location, can be viewed at westernunion.com.au, and have been summarised on the back of th is form for reference only. You agree to those terms and conditions by signing this form.

By signing this form, you: 1. Expressly consent to the transfer of your personal data entered above to WU Affiliates located ou tside of the European Economic Area, including to the U.S. for the purpose of providing the money transfer service to you and undertaking the additional data processing activities specified in the Data Protection section of the terms and conditions. You have the right to withdraw your consent at any time. 2. Expressly consent to the carrying out of profiling activities and marketing communications. 3. Confirm that the information you have provided is correct and that you have read and accepted the terms and conditions of the service overleaf.

Customer’s Signature

Date (DD/MM/YYYY)