REQUEST FOR ECASH REFUND (* = Mandatory fields)

GCI Account Information (Details of the account that the funds will be taken from)

*Account Number:

Ordering Customer (Your details)

*Name:  
*Street:
*Town / City:
*State / Country:
*Telephone1:
*Email:

eCash Account Information(Your bank details)

*eCash Account Type: Account Details
*eCash Account Number:
*Wallet Network:
*Wallet Address:

Identification Required

Please send the following documents if not supplied already:

	GCI use only
	On file	Date Recd
1. Passport copy (NOT ID CARD)
2. copy of front and back of card (blocking out the first 12 digits if you wish)
3. copy of a utility bill or bank statement showing the credit card billing address

Additional

*Will you be closing your GCI account?
*Any comments on our service?

Authorised Customer Signature:
I / We accept that this request is governed by the Accounts General Terms & Conditions of GCI Financial LTD.

*Place & Date:

*Signature:

All information provided will of course be kept CONFIDENTIAL.
Please scan the document(s) to [email protected]