Clearance Form

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Name *

First

Last

Phone Number *

Phone number registered in your account

Total contribution amount made to date. *

How many accounts do you want to clear?

Account ID Number *

Put in the Account IDs Number you want to clear

Do You have outstanding default Payments

How much is your default outstanding Payment

Go and clear all outstanding payment before you fill this form

of Name Total

Name of Bank *

Account Number *

Account Name

Note that your account name must correspond with name used during reppppgistration.

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