CHANGE OF BANK DETAILS

EXISTING ACCOUNT DETAILS

Date changes will be effective from

Bank name

Account name*

Sort code

Account number

*Account name should match the registered corporate name from section 1

3. Proof of Bank Account

Please attach and enclose proof of your new business bank account details. This must be an original version of one of the following:Pay slip Void cheque Bank statement (this can be an online printed version providing it shows the url/web address)

ISXPay is operating in Australia as Authenticate Pty Ltd, ABN 49 600 573 233, of 456 Victoria Parade, East Melbourne, 3002, Victoria, and in Europe as iSignthis eMoney Ltd, HE348009, 26 Athalassas Avenue, Strovolos 2018, Nicosia, Cyprus. Pricing is subject to merchant due diligence and approval. Standard Terms and Conditions apply. October 2017

Signed for and behalf of the Customer

NEW ACCOUNT DETAILS

Bank name

Account name*

Sort code

Account number

Registered corporate name

Registered address

Business address (if different from registered address)

Phone number Fax number Email

Business name (if different from registered corporate name)

CountryPostcodeCity

1. The business

2. Bank account details

www.isignthis.com | merchant.support@isignthis.com

Position held Date

Authorised signature Name