APPLICATION FORM FOR INTERBANK GIRO
 
    PART 1: FOR APPLICANT'S COMPLETION
  Date:   Name of Billing Organisation ("BO"):
   
  _____________________________________ ___________________________________________
   
  To: Name of Financial Institution:   Billing Organisation's Customer's Name:
   
  _____________________________________ ___________________________________________
   

  Branch:

  Billing Organisation's
  Customer's Reference Number:

   
  _____________________________________ ______________________________________
   
  (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 ebit 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 authorisation wil 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.
  My/Our Name(s):   My/Our Contact (Tel/Fax) Number(s):
   
  ____________________________________   __________________________________________
   
  My/Our Account Number:   My/Our Company Stamp/Signature(s)/Thumbprint(s)*:
   
  ____________________________________   ___________________________________________
  (As in Financial Institution's record)
PART 2: FOR BILLING ORGANISATION'S COMPLETION
  Bank   Branch   Billing Organisation's Account No.   Billing Organisation's Customer Reference
                                                                 
  Bank   Branch   Account No. to be debited.  
                                   
PART 3: FOR FINANCIAL INSTITUTION'S COMPLETION
 
To:
This Application is hereby REJECTED (please tick) for the following reason(s):
 
Signature/Thumbprint# differs from Financial Institution's records Wrong Account number
Signature/Thumbprint# incomplete/unclear# Ammendments not countersigned by customer
Account operated by signature/thumbprint# Others: ________________
 
 
___________________________ _____________________ _____________________
Name of Approving Officer Authorised Signature Date
 
  *For thumbprints, please go to the branch with your identification #Please delete where inapplicable