Agent

Account Name：*

Account No：*

ID：*

Phone：*（Note: Country code+area code+number）

Address：*

Withdrawal of household：*

Payment amount：*

Account @ Wallet Address：*

Bank @ Wallet Name: * (Note: must be the same as account name)

Bank address：*

Bank account @ wallet address: * (Note: must be consistent with the account opening registration information)

Applicant：*

Application date：*

E-mail：*

Code：*