EFTA00616687.pdf

1First Bank Transfer Application (SHADED AREAS FOR BANK USE ONLY) BRANCH NO. PREFIX TEST KEY DATE TIME TRANSFER TYPE: El WIRE . CABLE ❑ DRAFT ❑ Mall to Customer • Mal to Payee 0 Send to Branch REP SIGNATURES (Complete appropriate boxes): KEY MODIFY MODIFY APPROVE IF TRANSFERRING FOREIGN CURRENCY: CONTRACT NO VALUE DATE CONVERSION RATE CONVERTED BY (Initials) TRANSFER AMOUNT: FOREIGN CURRENCY (TYPE AND AMOUNT) TRADER'S NAME U.S. DOLLARS $ 71,012.00 NOTE' ADDITIONAL FEES $ • Foreign currency amount multiplied by the exchange rate = U.S. dollar Amount • U.S. Dollar amount divided by the exchange rate = Foreign Currency Amount. TOTAL AMOUNT 6 71,01200 METHOD OF PAYMENT: INTERMEDIARY CORRESPONDENT BANK: (IInecessary) DEBIT ACCOUNT NO. DEBIT BRANCWDEPT. NO. ABA ROUTING NO./SWIFT CODE 08 NAME/ACCOUNT TITLE BANK NAME LSJ, LLC MAIUNG ADDRESS: ADDRESS do Financial Trust Co., Inc. 6100 Red Hook Quarter, B3 PHYSICAL ADDRESS: 6100 Red Hook Quarter, 83 CITY. STATE. ZIP CODE. COUNTRY CRY, STATE, ZIP CODE, COUNTRY St. Thomas, VI 00802-1348, USA TO: PAYEE/BENEFICIARY'S BANK FOR: PAYEE/ACCOUNT OF ULTIMATE BENEFICIARY ACCOUNT NO. lift BANK NAME NAME/ACCOUNT TITLE Darby Bank & Trust TSG Technologies, Inc. ADDRESS ADDRESS 327 Eisenhower Dr. Ste. 100 CITY, STATE, ZIP CODE, COUNTRY CITY, STATE, ZIP CODE, COUNTRY Savannah, GA, 31406, USA Savannah, GA, 31406, USA ORIGINATOR REFERENCE: BENEFICIARY REFERENCE: I I I I I I I I I I I l i l t I I I I I I I I I I I I I I I SPECIAL INSTRUCTIONS: (Optional) Please email Fed. Reference number to Emad Hanna at THE UNDERSIGNED AGREES TO THE CONDITIONS ON THE REVERSE SIDE OF THIS APPUCATION. CUSTOMERS TELEPHON DATE OF APPLICATION 6/27/2007 CUSTOMER IGN R CUSTOMERS SIGNATURE (If Applicable) CUS ME T ER REQUEST: (Complete appropriate boxes) O FAX IN PERSON O PHONE 0 MAIUMESSENGER I.D. USED (Do not leave blank) ❑ ELEPHONE/FAX AGREEMENT ON FLE m ONE TIME ONLY ❑ CALL-BACK IF OVER S LIMIT: m TRANSACTION Ill By_ . _ U Spoko to _ _ _ U Time HOLD PLACED TAKEN IN BY (Print Name) INITIALS TEST KEY CALCULATED BY (If different than taken in by) I INITIALS BRANCH AUTHORIZED SIGNER (Print Name) BRANCH TELEPHONE NO. BRANCH AUTHORIZED SIGNATURE ( ) - NNAN-2196.0802 EFTA00616687