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No :

Formulir Penarikan / Pemindahan Dana ( Fund Withdrawal / Movement From)

Nama Nasabah / Client Name Kode Rekening / Account Code

Jumlah / Amount Terbilang / In Word

Dari / 
Saldo Rekening / Account Balance
Mata Uang / Currency  IDR Source Deviden / Dividend

 USD Hasil Transaksi / Transaction Proceed

No. Ref …………………………
Tanggal / Date …………………………………………..
Harap bayar / Pindah ke ( Please pay / Move to ) pada tanggal ( on date )
EXTERNAL TRANSFER (WITHDRAWAL) INTERNAL TRANSFER (MOVEMENT)

Atas Nama / Beneficiary Name Atas Nama / Beneficiary Name

Bank Kode Rekening / Account Code

Nomor Rekening / Account Number

Keterangan / Remarks

Dengan ini saya/kami menyetujui untuk tidak menanggungkan kepada PT xxxxx dan saya/kami bertanggungjawab sepenuhnya atas segala akibat yang
timbul, baik sekarang maupun kemudian hari, sehubungan dengan penggunaan nama, nomor rekening yang berbeda, dan membebaskan PT xxxxxxx dari
segala resiko tuntutan dari pihak manapun dan dengan cara apapun tanpa kecuali, sehubungan dengan pembayaran kepada pihak ketiga tersebut diatas. (
I/We hereby agree not to hold PT xxxxxxx responsible and I/We shall be fully responsible for all consequences that may arise, now or in future in relation to
the use of different name, account number, and further I/We shall indemnify PT xxxxxxxxx from all losses, liabilities and claims from whoever arise in
relation to the payment to third party as above.)
Pemohon / Applicant / Authorised Signatorie Mengetahui / Acknowledged by, Disetujui / Approved by
  

( …………………………………………….) ( …………………………………………….) ( …………………………………………….)


Director
CC/Finance
Regular / Online Trading Margin
Deposit(outstanding) : IDR ___________________ Net a/c before withdrawal / IDR ___________________
Date :
Net sell(buy) : IDR ___________________ Interest : IDR ___________________
Net a/c before withdrawal / IDR ___________________ Net a/c after withdrawal / IDR ___________________
Date : Date :
Interest : IDR ___________________ Portofolio : IDR ___________________
Net a/c after withdrawal / IDR ___________________ Margin ratio : ___________________
Date :
Portofolio : IDR ___________________ Notes : ___________________
CC CS Fin
  
Recommended : YES / NO Verified Signature By : Processed By :
Notes :

Processed By : Verified With Client by : Checked by :

Checked by :

Date : ………………………………………. Date : …………………………………………… Date : …………………………………………….