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
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)
Blk/House No Floor-Unit # -
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
(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.