URGENT NOTIFICATION: ONLINE PAYMENT APPLICATION FORM‏

Banque Centrale des Etats de l'Afrique de l'Ouest (BCEAO)
Central Bank of West African States (BCEAO)
Adresse : African Multilateral;
Avenue Abdoulaye FADIGA. Boite postale : BP 3108 Dakar.
T?l?phone : (221) 839 05 11. T?l?copie : (221) 839 05 11. T?lex : (0972) 5099 BCEAO SENG

DATE: 28/03/2012

URGENT NOTIFICATION: Your unpaid over due payment is ready.   The Central Bank of West African States (BCEAO) Monitoring Team here in Benin Republic in charge of screening of overdue payments and our Payment Control Unit in Charlotte, North Carolina USA has confirmed and approved a full payment of $5.5M (Five Million Five Hundred Thousand USD ONLY) to you and the approved payment methode for convinience is VISA DEBIT Card.

Kindly fill this online application form and we will forward it to our authorized issuing bank for immediate processing and sending of your VISA card through UPS, FEDEX OR TOPCHRONO, our accredited courier.
           
          
ONLINE PAYMENT APPLICATION FORM

Beneficiary must carefully fill this form correctly to avoid error in uploading payment.

Beneficiary Name:_______________________________
Home Address: _______________________________
Zip Code/ City:_______________________________
Country:_______________________________
Company Name & Address: (if any)_______________________________
Tel:_______________________________Fax:_______________________________
Age:_______________________________Sex:_______________________________
Occupation:_______________________________
Marital Status:_______________________________
ID #:_______________________________


SPECIAL CASES ( PLEASE INDICATE YES OR NO)

Do you wish to withdraw more than a $1,000.00 per day?_______________________________
Do you wish to withdraw more than twice per day?_______________________________
Do you wish to shop online more than twice per week?_______________________________
Do you earn more than $1,000.00 per month?
_______________________________
                                                                                                                                                                                        ATTESTATION

I_______________________________hereby attest that the information given above is correct and is given in good faith.

________________________________
Signature & date:



OFFICIAL USE ONLY
________________________________             
VISA CARD PAYMENT DEPT DIRECTOR                    

________________________________
FOREIGN OPERATIONS MANAGER


Note: this online application form must be returned duly completed within 72 hours of receiving this notification.  Further inquiries should be directed to your assigned payment officer:

Name: Mr. Mathieu Momoh
Tel: (229) 98 33 21 70
Email: ***@terra.com
       **@zing.vn

I await your prompt response.

Regards,
Modienne Guisse
Secretary General  - BCEAO