Standing Order Request Form
Customer Information
Account Number
*
Branch
*
Basseterre
Charlestown
Pelican Mall
Sandy Point
Customer Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Beneficiary Information
Beneficiary Name
First Name
Last Name
Company Name
Beneficiary Account Number
*
Beneficiary Account Type
Beneficiary Bank
Routing Number
Payment Information
Amount
*
Reason for payment
*
First Payment Date
*
-
Month
-
Day
Year
Date
Payment Frequency
*
One-time Payment
Weekly
Bi-weekly
Monthly
Quarterly
Annually
Day of payment
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Validity Period
*
Until further notice
Specified Date
Final Payment Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
By signing this form, I confirm that I am duly authorized to perform this request. I also authorize the St. Kitts-Nevis-Anguilla National Bank ("the Bank") to debit my account for the associated fees. The Bank is not liable for any payment which has not been effected on the due date owing to lack of funds. The Bank may, at its discretion, cease to carry out this instruction WITHOUT NOTICE if there are insufficient funds in the designated account for three (3) consecutive periods.
*
Please use your mouse or touch device to draw your signature.
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