Transcript No Slide Title

PREAUTHORISED DEBIT PAYMENT - AUTHORISATION AGREEMENT
BELGIUM
Customer Name :
SWIFT code (BIC or PIC):
Address :
City :
Country :
E-mail:
Important notices:
- Any new customer joining the SWIFT Service is required to register to the direct debit mechanism for
the payment of all its SWIFT invoices.
- To
speed up the activation of your direct debit, please complete the form and request
your correspondent bank to stamp and sign for approval prior to returning to SWIFT.
We, hereinafter called Customer, authorise S.W.I.F.T. s.c.r.l., to originate and transmit electronic debit and credit
entries in EUR 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 bank account in EUR in Belgium either within your financial institution
or with a correspondent Bank in Belgium.
Correspondent Bank Name :
Correspondent Bank BIC code :
Account number :
-
-
(Please respect the maximum number of digits)
Person/Dept. we may contact for possible questions:
RESERVED FOR CORRESPONDENT BANK APPROVAL
Pre-authorized debit authorisation number:
Date: _________________
Identification number of creditor
0
0 4
1 3 3
3
0
Stamp and signature
8 5 6
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 9