You just put your information into the little white box there. Make sure to include all the information they ask for.
My problem is there is no "little white box" in which I can set the beneficiary.
I see only "amount to withdrawal" and "purse", whose meaning I don't really understand.
Here's a screenshot of what I see, can you point at the "little white box" you are referring to?
https://dl.dropboxusercontent.com/u/4576782/btce_withdrawal_form-tn.jpg
