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["Please note that this form must be completed in full to create the correct entity details on the system(Please complete or mark with a \"X\" in black ink where applicable. A bank stamp is required to verify your banking details. In case of a cheque account a cancelled cheque must be included. Please return form by post or by hand delivery or by facsimile.)"]
["TAKE-ON:",{"$nulls":4},"NEW",{"$nulls":3},"UPDATE",null,null,"ENTITY TYPE:",{"$nulls":3},"BUSINESS",{"$nulls":3},"DEPARTMENT",{"$nulls":4},"EMPLOYEE",{"$nulls":3},"OTHER"]
[]
[]
[]
["FROM: CREDITOR / ENTITY (DETAILS)",{"$nulls":4},"TITLE"]
[{"$nulls":5},"SURNAME"]
[{"$nulls":5},"FIRST NAME/S"]
[{"$nulls":5},"BUSINESS NAME",{"$nulls":19}," "]
[{"$nulls":5},"TRADING NAME"]
[{"$nulls":5},"BUSINESS REG No.",{"$nulls":10}," "]
[{"$nulls":5},"VAT REGISTERED",{"$nulls":5},"Y","N"]
[{"$nulls":5},"VAT REGISTRATION NO."]
[{"$nulls":5},"ID NO."]
[{"$nulls":5},"DEPARTMENT NAME"]
[{"$nulls":5},"PERSAL NO. *",{"$nulls":13},"* For employees only"]
[]
["CONTACT DETAILS",{"$nulls":4},"STREET / PHYSICAL ADDRESS"]
[]
[]
[{"$nulls":22},"POSTAL CODE"]
[]
[{"$nulls":5},"POSTAL ADDRESS"]
[]
[]
[{"$nulls":22},"POSTAL CODE"]
[]
[]
[{"$nulls":5},"BUSINESS TELEPHONE No.",{"$nulls":14},"DIALLING CODE"]
[{"$nulls":5},"BUSINESS FACSIMILE No.",{"$nulls":14},"DIALLING CODE"]
[{"$nulls":5},"NAME OF CONTACT PERSON"]
[{"$nulls":5},"E-MAIL ADDRESS"]
[{"$nulls":5},"CELLULAR TELEPHONE No."]
[]
[]
["DETAILS OF FINANCIAL INSTITUTION FOR ELECTRONIC BANKING TRANSFERS:"]
["BANK NAME:",{"$nulls":19},"BANK DATE STAMP (COMPULSORY)"]
[]
["BRANCH NAME & CITY/TOWN"]
[" "]
["BRANCH NUMBER/CODE"]
[]
["ACCOUNT NUMBER"]
[]
["ACCOUNT TYPE",{"$nulls":5},"CURRENT",{"$nulls":3},"SAVINGS",{"$nulls":3},"TRANSMISSION"]
[]
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[" I / We hereby request, instruct and authorise you to pay any amounts which may accrue to me / us to the credit of  my / our account with the abovementioned bank."]
[" I / we understand that the credit transfers hereby authorised will be processed electronically through a system known as the \"ACB ELECTRONIC FUNDS TRANSFER SERVICE\", and I/we also understand that no additional advice of payment will be provided by my/our bank. Details of each payment will be printed on my/our bank statement or any accompanying voucher. "]
["I / We understand that a payment advice will be supplied by the Department in the normal way, and that it will indicate the date on which funds will be available in my / our account."]
["This authority may be cancelled / changed by giving prior written notice, by way of registered post or facsimile."]
[]
["SIGNATURE OF AUTHORISED PERSON",{"$nulls":17},"POSITION HELD"]
[]
[]
["PRINT NAME OF AUTHORISED PERSON",{"$nulls":16}," ","DATE (DD/MM/YYYY):",{"$nulls":4}," ",null,null," ",null,null," "]

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