Equity Form Stp 071 – Fill Out and Use This PDF

Standing Order Request Form

Please efect the instructions below on my/our behalf

[ ] New

[ ] Amend

[ ] Cancel

CUSTOMER’S DETAILS

Account Name:

Account No.:

Address:

Code:

Town:

Phone No.:

e-mail address

RECIPIENT/ BENEFICIARIES DETAILS

Beneiciary Name:

Account No.:

Bank Name:

Branch Name:

STANDING INSTRUCTION

Pay amount in igures:

in words

Every (DATE)

Frequency Monthly[ ] Quarterly[

] Yearly[

] Weekly [ ] Others (Specify)

From my account to beneiciaries accounts indicated above Starting Date:

and End on Date

being payment of

Reference (Policy No., Loan A/c etc):

For amendments indicate details to be amended in the box below:

Terms and conditions of Standing order:

•he bank does not undertake to efect ater the due date, any payment which was not efected on the due date owing to lack of funds.

•he customer shall ensure that there are suicient funds in the account before the due date to enable the bank to efect these instructions.

•he bank hereby reserves the right to cancel this standing instruction without notice to the customer if the standing instruction has failed and payments could not me made for three consecutive times due to lack of funds, the account being blocked and/or account being dormant or any other reason(s) which is/are due to acts and/or omissions of the customer. he bank shall not liable for such cancellation, failure to execute or insuicient execution of the instruction or any direct and/or indirect consequences that may arise from the same.

Authorised signatories

By signing this standing order request form, I/We have read, understood and agreed to be bound to the terms mentioned herein and I/We have signed in agreement to the same and conform that the information supplied in this form is correct to the best of my/our knowledge. I/We accept full responsibility for all such instructions and for ensuring the accuracy and completeness of these instructions.

Name:		ID No.		Signature:
Name:		ID No.		Signature:
Name:		ID No.		Signature:

For Bank Use Only

To be completed by indicating user ID, oicial signature and number as appropriate

Received by:

SI Details Veriied By:

Conirmed By:

HO Maintaining call back needed? [

] No [ ] Yes talked to:

Tel No

Comments:

Call By:

Tran ID

Input By:

Veriied By:

Date:

STP 071