TV Licence Application Form
Unique Mandate
Reference
T V V
(Unique Mandate Reference will be created by TV Licence records office)
Creditor Identifier
Bank Account Holder
Name:
*
(Name on Debtor's Bank Account)
Bank Account Holder
Address:
*
City/Post Code:
*
Country:
*
Bank Account Holder's
IBAN Number:
*
Bank Account Holder
Identifer Code -
BIC / SWIFT:
*
Creditor Name:
An Post (TV Licence)
Creditor Address:
1-2 Upper O'Connell Street
City:
Dublin 1
Country:
Ireland
Type of Payment:
Recurrent payment
Date of signature: *
D D M M Y Y Y Y
Signature(s): *
(Authorised Signatories of Bank Account Holder above)
Block Capitals: *
SEPA Direct Debit Mandate
PART 2 of 2
IE48ZZZ300450
Please complete all the fields below marked *
Note: Your rights regarding the above mandate are explained in a statement that you can obtain from
your bank.
By signing this mandate form, you authorise (A) An Post (TV Licence) to send instructions to your bank
to debit your account and (B) your bank to debit your account in accordance with the instruction from
An Post (TV Licence).
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of
your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which
your account was debited.
TVMandate Issue 1 October 2013
Page 2/2
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TV Licence Application Form PDF
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