GIRO Application Form (TV)

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GIRO Application Form (TV) Powered By Docstoc
					GIRO Application Form (TV)
Please mail the completed GIRO application form to:
Media Development Authority
Customer & Licensing Services
3 Fusionopolis Way, #14-22 Symbiosis, Singapore 138633

This form may take you about 5 to 10 minutes to complete.
Part 1: For Applicant’s / Licensee’s Completion

                                                             Name of Billing Organisation: Media Development Authority
Date (dd/mm/yy)                                              To: Name of Bank or Financial Institution

           /              /

Licence Number                                               Branch




NRIC / FIN / Passport / ACRA / ROS Number                    Licence Type:      Residential TV -     Owner or            Tenant
(Please delete where inapplicable)                                              Non-Residential TV    - No. of TV sets
                                                                                Dealers’

                                                       Payment Scheme:          Yearly Deduction or          Monthly Deduction

Licensee’s Full Name in Block Letters as in NRIC / FIN / Passport / ACRA Reg / ROS (please underline your surname)



Licence Address

Blk/House No                                  Floor-Unit #                 -

Street Name

Building Name                                                                                                                 Postal Code

(a) I/We hereby instruct you to process MDA’s instructions to debit my/our account.
(b) Any refund will be credited to my /our account.
(c) You are entitled to reject MDA’s debit 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 any charge(s) incurred on me/ us accordingly.
(d) This authorisation will remain in force until terminated by your written notices sent to my/our address last known to you or upon receipt of my/our
    written revocation through MDA.

Bank Account Holder’s Name(s)



Bank Account Number                                                                        Signature(s)/Thumbprint(s)/Company Stamp



Telephone Number



                                                                                           (As in Bank’s or Financial Institution’s records)
                                                                                           For thumbprint(s), please go to the respective branch with your identification.


Part 2: For Media Development Authority’s Completion

 Bank               Branch           MDA Account No.                                                                              Licence Number
 7 3 7          5   0 0 1            1 0 1 3 2 1              7    7   7   2

 Bank                Branch          Account No. to be debited
                                                                                                                                  New / Renewal

Part 3: For Bank’s or Financial Institution’s Completion
To: Media Development Authority
This application is hereby REJECTED (please tick) for the following reason(s): (# please delete where inapplicable)
  Signature/Thumbprint # differs from Bank’s or Financial Institution’s records               Wrong account number
  Signature/Thumbprint # is incomplete/unclear #                                              Amendments not countersigned by customer
  Account operated by Signature/Thumbprint #                                                  Others:




Name of Approving Officer                                         Authorised Signature                                    Date

NOTE : Faxed copy of the GIRO application form will not be accepted as the bank requires your original signature for verification.
                                                                                                                                      MDACLS 3F.008.7.200809