Your Existing Order Number: *
New / Modified Order Details:
Sell: *
Pecunix
C-gold
Liberty Reserve
Global Digital Pay
Your Gold Account Number : *
Your Gold Account Name : *
Batch Number of your Spend: *
(transaction #)
(If you forgot to copy your Batch/Trasaction Number, look for it in your account History)
Desired Payment Method: *
US Bank Wire ($35) US Check ($10.-) Intl Bank Wire ($55) (on top of Sell Fee)
Gross Amount sold (US$): *
(99999.99 format)
Example: 1500.25 : Do NOT use «, » (commas) in the Amount sold
You will receive:
US$ (NET , After Fees)
Personal Details:
Your First Name: *
Your Last Name : *
Your e-mail Address: *
(Land line) Home phone: *
(555-999-1234 format)
Office / Mobile phone: *
(555-999-1234 format)
Your Home Address: *
Your Zip code: *
Your City: *
State: *
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Select your Country: *
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Banking Details:
Fill the Fields below for Bank Wires only , in which case informations are required
Bank Name:
Fedwire ABA Routing #:
(SWIFT Code for Intl.)
Note on ABA routing: (USA only) You MUST provide the Fedwire ABA
or there will be delays. Call your Bank to verify valid "Fedwire ABA "
Beneficiary Account Name :
FULL Beneficiary Address :
(Nb,Street,City,State,Zip,Country)
Bank Account Number :
FULL Bank address:
(Nb,Street,City,State,Zip,Country)
Modifications Made: *
Additional Info /
Special Instructions:
By submitting this form, you agree to abide by our Terms and Conditions as described in our Disclaimer page
Please VERIFY that ALL Options, Amount, and other information,
data, etc above are Correct BEFORE submitting the form!
Incorrect Data would result in delays, and/or additional charges
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