MERCHANT REGISTRATION FORM

SECTION A
ESTATE INFORMATION:
NAME OF ESTATE/COMPANY: RC NUMBER

OFFICE ADDRESS: LOCAL GOVT/STATE:

WEBSITE ADDRESS: E-MAIL ADDRESS:

OFFICE TELEPHONE TELEPHONE 2 BUSINESS FAX NUMBER:

SECTION B
PAYMENT CHANNELS:

S/N CHANNELS YES/NO (Y/N)

1 BANK BRANCH
2 CARD
3 DIRECT DEBIT

SECTION C
NAME OF CONTACT PERSONS
S/N FULL NAME PHONE NUMBER E-MAIL

SECTION D (ACCOUNT DETAILS)

BANK NAME___________________________________________________
ACCOUNT NAME_______________________________________________

ACCOUNT NUMBER_____________________________________________

We, on behalf of ………………………….…………………………………………………

hereby certify that the information provided on this form is true and accurate. I
agree that _______________________ reserves the right to take appropriate
measures including legal actions if the information here is discovered to be
false.

SIGNATURE_____________________ DESIGNATION____________________DATE___________

SIGNATURE_____________________ DESIGNATION____________________DATE___________

FOR OFFICIAL USE ONLY

ESTATE ID________________________________________

RELATIONSHIP OFFICER NAME_____________________

RELATIONSHIP OFFICER SIGN OFF__________________

DATE____________________________________________