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<strong>CUSTOMER</strong> <strong>PAYMENT</strong> <strong>FORM</strong><br />
<strong>Airtel</strong> Networks Limited,<br />
Plot L2, Banana Island,<br />
Ikoyi, Lagos.<br />
Tel: +234 (0) 802 1901 500, +234 (0) 802 190 1501<br />
Fax: +234 (0) 802 190 1503<br />
www.ng.airtel.com<br />
CHANNEL NAME_________________________________________<br />
CREDIT CONTROL REFERENCE_______________________________<br />
CHANNEL CODE________________________________<br />
SUBSCRIBER ACCOUNT NO______________________<br />
PACKAGE CHOSEN________________________________________ CORPORATE INDIVIDUAL<br />
BILLING <strong>PAYMENT</strong>S DETAILS<br />
Customer Name__________________________________________________________________________________________<br />
Contact Person for Billing Enquires___________________________________________________________________________<br />
Contact Phone _____________________________________________<br />
Fax________________________________________<br />
E-mail Address___________________________________________________________________________________________<br />
House No/ Street Name____________________________________________________________________________________<br />
Nearest Landmark_________________________________________________________________________________________<br />
Area/ LGA_______________________________________________________________________________________________<br />
Town_____________________________________________________<br />
Preferred method of receiving bills: E-bills<br />
State_____________________________________<br />
Post<br />
Preferred method of payment: Cash Cheque Direct Debit (Fill mandate below)<br />
Requested Credit Limit _______________________________________<br />
Approved Credit Limit______________________<br />
DIRECT DEBIT MANDATE<br />
Contact Person for Billing Enquires___________________________________________________________________________<br />
Name of Account__________________________________________________________________________________________
Bank Name______________________________________________________________________________________________<br />
Account Name__________________________________________________<br />
Account Type____________________________<br />
Branch Address___________________________________________________________________________________________<br />
Branch Phone Number_____________________________________________________________________________________<br />
I HEREBY AUTHORISE MY BANK TO DEBIT MY ACCOUNT DETAILED ABOVE WITH ALL BILLS PRESENTED IN MY NAME BY<br />
AIRTEL NETWORKS LIMITED.<br />
Signature_______________________________________________________<br />
Date___________________________________<br />
DECLARATION<br />
I/ We hereby certify that all the information provided is correct. I/ We authorize <strong>Airtel</strong> to use the information therein to<br />
process the application for Network Services. I/ We hereby acknowledge upon acceptance for Network Services by <strong>Airtel</strong>, a<br />
contract will commence. I/ We confirm that we have been provided with a copy of the Terms and Conditions and have read<br />
and understood the same.<br />
Signature____________________________________________________<br />
Authorized Signature/ Date_______________
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