APPLICATION FORM FOR INTERBANK GIRO

Part 1: FOR APPLICANT'S COMPLETION(fill in the spaces indicated with ✓)

Date:

Name of Billing Organization(BO)

To: Name of Bank

Billing Organization's Customer's Name

Branch:

Billing Organization's Customer's Reference Number(BO)

Payment Limit:
(Maximum amount to be deducted per transation)

✓________________________________________ 		Expiry date of this authorization


✓________________________________________

(a) I/We hereby instruct you to process the BO's instructions to debit my/our account.
(b) You are entitled to reject the BO's debit instruction if my/our account does not have sufficient funds and charge me/us a fee for this. You may also at your discretion allow the debit even if this results in an overdraft on the account and impose charges accordingly.
(c) This authorization will remain in force until terminated by your written notice sent to my/our address last known to you or upon receipt of my/our written revocation through the BO.
(d) It is the BO's responsibility to inform banks upon the expiry of this authorisation and to ensure no deductions are made thereafter.
Note: BO's should print and make clear whether this option is applicable or available to their customers.

My/Our Name(s) as in Bank's records:

✓________________________________________ 		My/Our Contact(Tel/Fax) Number(s)

✓________________________________________
My/Our Account Number

✓________________________________________ 		My/Our Company Stamp/Signature(s)/Thumbprint(s)*:

✓________________________________________

Part 2: FOR BILLING ORGANISATION'S COMPLETION

Bank Branch Billing Organisation's Account Number
Bank Branch Account Number to be debited
Billing Organisation's Reference Number

Part 3: FOR BANK'S COMPLETION

To: Billing Organisation

This Application is hereby REJECTED(please tick) for the following reason(s):

( ) Signature/Thumbprint# differs from Bank records
( ) Signature/Thumbprint# incomplete/unclear#
( ) Account operated by signature/thumbprint#
 ( ) Wrong account number
( ) Ammendments not countersigned by customer/BO
( ) Others ________________________________
______________________________
Name of approving officer 		______________________________
Authorised signature 		______________________________
Date
* For thumbprints please go to the branch with your identification
# Please delete where applicable