APPLICATION FOR INTERBANK GIRO

PLEASE MAIL OR COURIER THIS FORM TO CRIMSONLOGIC PTE LTD (ATTN: CUSTOMER ADMIN).
FAX SUBMISSION WILL NOT BE ACCEPTED.
* Mandatory field
Date *:  (dd/mm/yyyy)
To : Name & Address Of Financial Institution *
Branch * :
Name of Billing Organisation ("BO"):
CrimsonLogic Pte. Ltd.
Billing Organisation's Customer's Name :
 
To be completed by CrimsonLogic
Billing Organisation's Customer Ref No.
                       
(a) I/We herby instruct you to process the BO's instruction 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 this. You may also at your discretion allow the debit even if this results in overdraft on the account and impose charges accordingly.
(c) This authorisation 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.
My/Our Account Name (s) * :
My/Our Account Number * :
My/Our Contact (Tel/Fax) Number (s) * :
My/Our Company Stamp/Signature(s)/Thumbprint(s)*:
_____________________________________________________________________
(As in Bank's records)
Bank Branch Billing Organisation's Account No.
7 1 7 1 0 1 2 0 1 2 0 0 5 4 6 8 8
Billing Organisation's Customer Ref No.
Bank Branch Account No. To Be Debited
   
To : Billing Organisation
This Application is hereby REJECTED (please tick) for the following reason(s) :
Signature/Thumbprint# differs from Financial Institution's records
Signature/Thumbprint# incomplete/unclear#
Account operated by signature/thumbprint#
 
Wrong account number
Amendments not countersigned by customer
Others :  ________________________________________
_______________________________
_____________________________
_____________________________
Name of Approving Officer Authorised Signature Date
* For thumbprints, please go to the branch with your identification.
Form CAS/cldda Rel 2.0 - Jan, 2010

CrimsonLogic Pte Ltd

31 Science Park Road, The Crimson, Singapore 117611, Main: (65) 6887 7888, Fax: (65) 6778 5277,
http://www.crimsonlogic.com/ (Regn No: 198800784N)