PAYMENT AUTHORIZATION FORM


The undersigned authorizes CellSave Arabia to charge his/her credit/debit card for the amounts to be invoiced for the services as specified in the Service Agreement in Section A and Fee Schedule in Section C.

SERVICE PROVIDED BY: CELLSAVE ARABIA FZ LLC

TOTAL AMOUNT:  

MONTHLY INSTALLMENT AMOUNT:  

CARDHOLDER'S FULL NAME:  

CARD NUMBER:  

EXPIRY DATE:  

BILLING ADDRESS:  

FIRST INSTALLMENT DATE:

LAST INSTALLMENT DATE:

CARD TYPE:

 

PAYMENT TERMS: 

Kit ID:

Client Email:  

Client Contact:  

I hereby confirm that I am the authorized holder of this card and have no objection for the beneficiary banker to check with me/my bank, which has issued the card. Instructions given by you shall be treated by my bank as instructions as if given by me personally. The number of the payment instructions may never exceed my indebtedness or obligations in terms of the agreements. The first payment instruction is to be delivered for payment to my bank on a date which is 3 days from the date hereof. Payment instructions must be given to my bank to correspond with the date so identified and selected, or as close as possible to such date, until such time as my obligations have been settled in full. I specifically agree that you may present two payment instructions in a payment cycle in the event that a past due payment was not honored. I agree that should my Primary Credit Card given failed for whichever reason, the secondary Debit Card can be used. I foresee that I may change my bank and bank account particulars reflect herein in which instance I am obligated to notify you of such change and provide you with my new bank particulars. Should I however not notify you, or you obtain my new bank particulars on your own account, this authority will not lapse and continue to cover such new bank information obtained. Such new bank particulars shall be read in conjunction with this signed authority by my new bank. I agree and understand that although this authority may be canceled; such cancellation will not cancel the agreement I have with you. I understand that I cannot reclaim payments made by my bank whilst such amounts still legally owed and due to you. This authority may be ceded or assigned to a third party, provided that the underlying agreement is also ceded or assigned.  

IF ANY ALTERATION OR MANIPULATION OF THE ABOVE DATA IS MADE THIS FORM WILL NOT BE VALID

 

 

 

For CellSave Office use only (Please do not fill-out the below information):

Logistics Department:  

Accounts Department:  

Client ID:  

 

Please fill-in the below Client Full Name and Email ID to receive a copy of CC Form.

Leave this empty:

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Signature Certificate
Document name: PAYMENT AUTHORIZATION FORM
lock iconUnique Document ID: 4736436327de631fa69eadb6c010c0c7b2b016d2
Timestamp Audit
July 12, 2023 9:15 am +04PAYMENT AUTHORIZATION FORM Uploaded by Cellsave Arabia - csait@cellsave.com IP 5.32.48.90
July 12, 2023 9:23 am +04CSA Agents - cs-agents@cellsave.com added by IT Cellsave - csait@cellsave.com as a CC'd Recipient Ip: 5.32.48.90
July 12, 2023 9:23 am +04CSA Finance - csa-finance@cellsave.com added by IT Cellsave - csait@cellsave.com as a CC'd Recipient Ip: 5.32.48.90
July 12, 2023 9:23 am +04Field Agents - fieldagents@cellsave.com added by IT Cellsave - csait@cellsave.com as a CC'd Recipient Ip: 5.32.48.90
July 14, 2023 10:35 am +04CSA Agents - cs-agents@cellsave.com added by IT Cellsave - csait@cellsave.com as a CC'd Recipient Ip: 5.32.48.90
July 14, 2023 10:35 am +04CSA Finance - csa-finance@cellsave.com added by IT Cellsave - csait@cellsave.com as a CC'd Recipient Ip: 5.32.48.90
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Audit Trail Serial# 0a4297cf2edc7e53a03b02b3577c6bd4