PAYBILLFORM

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Equitciw EQUITY i REQUEST FOR BUINESS NUMBER ORGANISATION DETAILS | [ORGANISATION NAME TYPE OF BUSINESS ZATEPHONE NUWBER (or SMS notification) » |_| POSTAL ADDRESS AND PHYSICAL ADDRESS | [EMAIC ADDRESS BUSINESS NUMBER DETAILS '3 PRFERRED BUSINESS NUMBERS T z 3. \ZERUTY COLLECTION RECOUNT RANE AND NOWET Validation of Data required (tick appropriately) Yes No Do you vant Biter Maintenanceas pes shor code yer C] ny Do you ned integration with your systems Yes w O If yes fill in below Connection information, i i CONNECTION ENVIRONMENT TEST ENVIRONMENTE ¢(u/vaut p+porvndpoi) | PRODUCTTONENVIRONVENT Ey Gi iiau py pRURVSTAT ENDPOINT URL ENDPOINT URL ever arising from wrong data su Completed by Applicant: Contact IT Technical Person: Name, .Phone Number. Account Signatories: Name... Signature, Name... Signature, Name... Signature... Date... For Official Use Only Name Date ‘Signature & Stamp Officer Supervisor Manager ‘BGDM/Operations Manager IO ADMINSTATOR CHECKED BY

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