ELECTRONIC FUNDS TRANSFER FORM

“Entirely Without Prejudice or Admission of Liability”

In order for us to pay your Distribution Royalties via “Electronic Funds Transfer” (EFT), kindly complete this
form and deliver the form to SAMRO (SAMRO Place, 20 De Korte Street, Braamfontein, Johannesburg,
Gauteng Province), or fax to 086 674 4391, or e-mail to customerservices@samro.org.za

Composer / Author

Surname Full Name(s)

Identity / Passport Number

Telephone / Mobile Number E-mail Address

Publisher

Company Name Company Registration Number

Telephone / Mobile Number E-mail Address

PLEASE ATTACH A COPY OF YOUR ID / PASSPORT, PROOF OF BANKING DETAILS (FIRST PAGE OF YOUR
BANK STATEMENT OR LETTER FROM THE BANK), AND PROOF OF RESIDENCE.

Banking Details

Account Holder’s Full Name(s) & Surname

Bank Account Number Branch Name / Code

Type of Account Cheque/ Transmission Savings/Mzansi

Current

I declare that the information given above is true and correct, and that I am authorised to sign in my personal
capacity or on behalf of the Company. Should any of the above information change at any time, SAMRO will be
notified immediately to avoid any delay in payments, or payment into an incorrect bank account. In addition, I
agree and accept that, in the event of the above information being incorrect, SAMRO will not be held responsible
for any delay and/or loss.

Account Holder’s Signature Date

PLEASE NOTE: WE ARE UNABLE TO ACCEPT PERSONAL ACCOUNT DETAILS FOR PUBLISHING COMPANIES