Transcript No Slide Title

PREAUTHORIZED DEBIT PAYMENT - AUTHORIZATION AGREEMENT
PREAUTHORISED DEBIT PAYMENT - AUTHORISATION AGREEMENT
UNITED STATES
Customer Name :
SWIFT code (BIC or PIC):
Address :
City :
Country :
E-mail:
Important notice:
Any new customer joining the SWIFT Services is required to register to the direct debit mechanism for
the payment of all its SWIFT invoices.
We, hereinafter called Customer, authorise S.W.I.F.T. s.c.r.l., to originate and transmit electronic debit and credit
entries in USD to our account indicated in this agreement.
A prenotification will be sent seven days before actual debiting/crediting of bank account (by MT999, fax or mail).
Customer understands that a debit entry will only be accepted if sufficient funds are available in Customer’s bank
account. In the event an invoice/credit note is not accepted for any reason, the Customer is to notify
S.W.I.F.T.s.c.r.l.within 30 days of invoice date by creating a case online or forwarding a mail to
[email protected].
Authorisation
Authorisation
Authorised signature :
Authorised signature :
Name :
Name :
Title :
Date :
Title :
Date :
Please indicate below the details of your USD account in the United States.
Correspondent Bank Name (or BIC code)
ABA number (9 digits) :
Bank Account number :
Person/Dept. we may contact for possible questions:
Please return the original form to: S.W.I.F.T. s.c.r.l., Credit and Collection, Avenue Adèle 1, B-1310 La Hulpe, Belgium
Telephone: +32 2 655 35 67 - Telefax: +32 2 655 37 43 - SWIFT BIC: SWHQBEBBFIN - Version 5 December 2003 - Page 16