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PRISCOMicrofinance Bank Ltd.

Authority to debit / transfer

Transfer Form

This is a customer transfer request. Submission does not itself execute a banking transaction.

Account Opening Loan Application Overdraft Transfer Form ✓Whistleblowing Data Access Request

01

Transfer Form

Fields marked * are required.

Select transfer officer *Date *Applicant / Customer Name *Identification Number *PRISCO Source Account Number *Amount *Beneficiary Account Number *Beneficiary Account Name *Beneficiary Bank Name *Mobile Number *

02

Customer authorization

Use either an uploaded signature or the electronic signature—not both.

Upload signature signed on plain white paperMaximum 1 MB, or sign electronically below.

Customer signature

I authorise PRISCO Microfinance Bank Ltd to debit my stated PRISCO account and transfer the stated amount to the beneficiary details supplied above. *

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