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Selcom Pay Change Request Form - Sept 2022

This document contains a registration form for merchants to provide new payment and contact details to an existing company account. Section I requests current company registration information. Section II is for a new bank account or mobile money wallet for settlement and collections. Section III allows updating contact names, phone numbers, and emails for notifications. Section IV requires acknowledgement of the terms and conditions.

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AFROIL MUSOMA
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110 views1 page

Selcom Pay Change Request Form - Sept 2022

This document contains a registration form for merchants to provide new payment and contact details to an existing company account. Section I requests current company registration information. Section II is for a new bank account or mobile money wallet for settlement and collections. Section III allows updating contact names, phone numbers, and emails for notifications. Section IV requires acknowledgement of the terms and conditions.

Uploaded by

AFROIL MUSOMA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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New Phone Number for SMS Notifications New Till Name


New Bank Wallet Details for settlement and collections New Email Address

Section I: Current Existing Company Registration Information


i. Company Registered Name:

ii. Trading Name:

iii. Till Number:


iv. Registered Address:

v. Town/City:

vi. GPS Lat. GPS Long.

Section II: New Company Payment Details


Please enter the new details of the Bank Account or Mobile Money wallet. Please ensure that you only fill one.

i. Bank Name: i. Mobile Money Wallet:

ii. Branch Address: ii. Mobile Money Recepient Name:

iii. Account Name: iii. Phone Number:

iv. Bank Account Number:

Acknowledgement below, I hereby con rm that the settlement information provided above is true. I also agree that Selcom shall not be responsi-
ble for the inaccuracy or falsi cation of the information provided by me, as the merchant. Selcom accepts no further responsibility after the funds
have been deposited into the account speci ed above. If the account details are incorrect, Selcom shall not be liable to me or any intended
bene ciary should money be debited or credited to the wrong account.

Section III: New Name, Mobile Number Email for Notifications


Pay Number 1 Pay Number 2

New Till Name New Till Name

Mobile Phone Mobile Phone

Email Address: Email Address

Section IV: Acknowledgement


I/We hereby declare that all information furnished herein is true and complete to my knowledge. I/We also agree to be bound by the Selcom
Pay Merchant Agreement. I/We further acknowledge and con rm that I/we have carefully read the provisions of the Selcom Pay Merchant
Agreement which are attached to this Form and have understood them and have not relied upon any statement, representation or waiver made
by Selcom Paytech LTD other than that set out in the Selcom Pay Merchant Agreement. I/We hereby irrevocably and unconditionally agree to
observe, ful ll and comply with the provisions of the Selcom Pay Merchant Agreement.

Authorized Signature:

Name:

Designation:

Company stamp
Date:

Section VI: For office use only

Selcom Representative:

Signature:

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