Selcom - Change Request Form

You might also like

Download as pdf or txt
Download as pdf or txt
You are on page 1of 1

CHANGE REQUEsT FORM

Pleare s.tect whatyou woutd


lke roLhangednd enrer new detarts in
se(flonr thdtare retevant bdred on
whdr y;u ,ete(ted.
the
L5EJLL rlt
E/New phone Number
for sMS Norifietions
!
n New Eank/WaIet Details for setrtement
and coIections
! -J/-
{1/}7to

iv. Beg srered Addresj o ?


€{- {
vi.GPS Lat.
GP5 Lonq

Pleaseenterthenewdetail5o'.n"'.nno..o,n.o,,oo,,**JIffi
[lobite MoneyWaIeri

ii. [,,lobileMoney RecepienrNam€:

iu Bank Account Number:

li"';:H:::x::[";t"ii::"'#:1;]lljl*::1lemp-, rro,marrcnprudedaoova-nu" d,od


,bvEoeenoeoo\treo,-rorn"*-,-'.,*m"a.r,.,I,?'o''o"aov'""ri",'.',;-,:"',;;.;::;;"'g""'h"r'e'(on\nar'norDer'<oo'-'
:
uen6-( drv hou'd no p! bpo-*o
* -**0.,i:''Jt";";'";" i "i^"''i"l' '""'
":ifl1'.'"fl:;:l'i',::?,:T::;:li;f["1,T."
6o a7i1-56 o 6.1'
- D-?---TTtooa-
oTYa ?6513(

l,/i1/eherebyde.]arethatal]nfotmationfurni5hedhereino".--,--F
,J:::il:.
;::,H:t#::*::::;
Agreementwhich are attached to
by5etcom paytech
:#;;:ffi
this Form and hav( de^toodth€m
LTDotherthan thatsetoutinthe
: ;:;:jTi:Ti:T:tffi1;1Ttff rons or rhe ::
and havenot relied upon anvstateirent,
fi ::ff: ::ffi
selcom Pay l\4erchant
representation orwaivermade
obseruefu6,,and.omp,yw,,,;;;;;;fr;;":::l;;il]:i:::ff:::::Avehe,ebv rrevo.ab,vanduncond,ona,yaeree,o

AILtF Wt BhtzDu t,
A FROIL INVESTMBNT lTD
0 tU e Prtt M tql\/ A 6{ lL p. O. Box 39303
DAR ES SALAA[,r
)eIrIto bd ,
Section Vt: For offiEiiiifi
Sel<om Rep.esentative:

You might also like