APPLICATION FORM FOR CHAN

PayU S.A.
182, Grunwaldzka Str.
60-166 Poznań
Poland
Tel. +48 61 628 45 05
Email: [email protected]
www.payu.pl
City: ………………………………...., date: …………………………………………
APPLICATION FORM FOR CHANGE OF BANK ACCOUNT NUMBER IN PAYU SYSTEM
In order to change your bank account number, fill out this application form and make a verification transfer from the
account to be introduced into the system in the amount of PLN 2 to account number 23 1140 1124 0000 5500 0700
1006. After the new number has been verified, the funds will be returned. Please send the application form to
[email protected]. In the e-mail and transfer titles type “Change of account” and enter your company tax identification
number (NIP).
Agreement number/Partner’s name:
.………………/………………………………………………………………………………………………………………………
……………………….……
…………………………………………………………………………………………………………………………………………
…………………………….
Partner’s registered office:
…………………………………………………………………………………………………………………………………………
……….……………………
Partner’s tax identification number (NIP):
……………………………………………………………
I apply for changing my bank account number as specified in this application form for withdrawal of
transaction funds (e-payments and payment cards).
Names/URL addresses of shops in the PayU system, the bank account number of which should be changed:
1.
…………………………………………………………………/
www.……………....................................……………………………
2.
…………………………………………………………………/
www.……………....................................……………………………
3.
…………………………………………………………………/
www.……………....................................……………………………
4.
…………………………………………………………………/
www.……………....................................……………………………
5.
…………………………………………………………………/
www.……………....................................……………………………
Current bank account number (in IBAN format):
P L
New bank account number (in IBAN format):
PayU SA, ul. Grunwaldzka 182, 60-166 Poznań, NIP 779-23-08-495, REGON 300523444, District Court for Poznań – Nowe Miasto and Wilda in Poznań, 8
National Court Registry, KRS 0000274399, Share capital: PLN 4.944.000 paid in full.
th
Commercial Department of the
PayU S.A.
182, Grunwaldzka Str.
60-166 Poznań
Poland
Tel. +48 61 628 45 05
Email: [email protected]
www.payu.pl
P L
--------------------------------------------------------------------------------------------------
Date and signature of persons authorised to represent the Partner:
When the application form and the transfer have been verified, PayU will change the funds withdrawal data in the PayU system. The applicant is informed about the
change by e-mail. The processing time should not exceed 48 hours (on business days).
PayU SA, ul. Grunwaldzka 182, 60-166 Poznań, NIP 779-23-08-495, REGON 300523444, District Court for Poznań – Nowe Miasto and Wilda in Poznań, 8
National Court Registry, KRS 0000274399, Share capital: PLN 4.944.000 paid in full.
th
Commercial Department of the