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Thomas Jefferson University
WIRE TRANSFER AUTHORIZATION FORM
Ø The individual and or department requesting the wire is responsible
for obtaining correct wire transfer instructions and necessary
signatures
Ø The University is not responsible for funds that are delayed or do not
reach the intended destination.
Deliver to Treasurer's Office, 511A Scott Building
Department Name:
Date:
Employee Name:
Phone Number:
Email:
Department General Ledger Number to be charged:
Departmental Approval:
Original signature required
Name/Title of Above:
WIRE TRANSFER INFORMATION
Amount of Payment:
Currency:
US Dollar
Beneficiary Bank Name:
Beneficiary Bank Address:
Payee Bank ABA Number:
For US Banks Only
IBAN:
SWIFT Code:
Required for Foreign Wire
Beneficiary Name/Bank Title:
Beneficiary Address:
Reference:
Requested Date of Transfer: