Page 1 of 2
F104 - Providers Payment Information
Company Name
*
Email Address
*
Email address authorised to manage payments
Company full address:
*
*
*
*
Type of account
*
Type of account
A
Personal
B
Business
C
Paypal
Account Currency:
*
Account Currency:
A
US dollars
B
COP
C
PEN
D
UYU
E
Other
Account Holder's full name*:
*
* Exactly as it appears in bank statement
Account Holder's full address
*
*
*
*
Bank Name
*
Bank address
*
*
*
Account number
*
*
Add another account?
*
Add another account?
A
No
B
Yes
Submit
