[md-form]

NAME
[md-text label="First Name"]
[/md-text]
[md-text label="Last Name"]
[/md-text]
[md-text label="Email"]
[/md-text]

BILL TO
[md-text label="Full Name"]
[/md-text]
[md-text label="Company Name"]
[/md-text]
[md-textarea label="Company Address"]
[/md-textarea]
[md-text label="Phone"]
[/md-text]

Coming From (if different from Bill To)
[md-text label="Full Name"]
[/md-text]
[md-select label="Relationship"]
Business PartnerAssociateOther[/md-select]
[md-text label="If 'Other' please state:"]
[/md-text]

TYPE OF SERVICE
PayPal Transfer (minimum US$200 submission amount)

[md-text label="Source of Funds"]
[/md-text]

ACCOUNT DETAILS
[md-text label="Name on account"]
[/md-text]
[md-select label="Financial Institution"]
NCBScotiabankCIBCSagicorOther[/md-select][md-text label="If 'Other' please state:"][/md-text]
[md-text label="Account Number"]
[/md-text]
[md-select label="Account Type"]
SavingsChequing[/md-select]
[md-text label="Routing Number"]
[/md-text]
[md-text label="Branch Location"]
[/md-text]
[md-text label="Branch Code"]
[/md-text]

[md-text label="Amount Sending ($)"]
[/md-text]

Evidence of Transfer
[md-file]
[/md-file]
[md-raw]Accepted file types: pdf, jpg, png[/md-raw]

[md-raw]

ALL TRANSFERS ARE DONE WITHIN 2 BUSINESS DAYS AFTER RECEIPT

TRANSFERS USUALLY TAKE 72 HOURS OR LESS BEFORE HITTING YOUR ACCOUNT

[/md-raw]

[md-captcha]
[recaptcha]
[/md-captcha]

[md-submit]

[/md-submit]

[/md-form]