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Satellic Direct Debit Application Form

If you would like to use the Satellic Direct Debit service to pay the toll, the following conditions generally apply:

  • Your company must be in good financial health;
  • You must provide two B2B SEPA direct debit mandates (via the form hereunder): one for the toll and one specifically for the use of the Liefkenshoek Tunnel service.
  • You must transfer a calculated deposit amount equivalent to twice your usual toll amount to the following Satellic bank account (BE64 0017 9630 9452), mentioning in the reference your company's name, your Satellic customer number and "SEPA B2B Deposit".

The detailed special conditions of the  Satellic Direct Debit (SDD) service can be found in the  document SDD Specific Terms and Conditions.
If you agree with those conditions, you can submit an application by completing and signing the Satellic Direct Debit Application Form below.

Note that this Satellic Direct Debit Application Form is submitted by the User* identified below. The word "User" is used pursuant to the definition given in the Satellic General Terms & Conditions (User Contract).

Address of the company's registered office
I confirm I have read and accept the SDD (Satellic Direct Debit) Special Conditions
The person signing this SDD Application Form on behalf of the User 
  •  confirms to have read and accept the SDD (Satellic Direct Debit) Special Conditions.
  • declares and guarantees that he/she has the necessary powers to sign this Satellic Direct Debit Application Form for and on behalf of the User. If this person is the only person signing for and on behalf of the User, such person represents and warrants that he/she has the necessary powers to sign the Satellic Direct Debit Application solely. 
The User
  • represents and warrants that all the information provided in this Satellic Direct Debit Application Form is correct and complete.
  • acknowledges that, by submitting this Satellic Direct Debit Application Form, he/she is bound by the SDD Specific Terms and Conditions, which shall form an integral part of the SDD Addendum that is part of the General Terms & Conditions (User Contract) between Satellic and the User.
I read and accept the SDD (Satellic Direct Debit) Special Conditions
The person signing this SDD Application Form on behalf of the User 
  •  confirms to have read and accept the SDD (Satellic Direct Debit) Special Conditions.
  • declares and guarantees that he/she has the necessary powers to sign this Satellic Direct Debit Application Form for and on behalf of the User. If this person is the only person signing for and on behalf of the User, such person represents and warrants that he/she has the necessary powers to sign the Satellic Direct Debit Application solely. 
The User
  • represents and warrants that all the information provided in this Satellic Direct Debit Application Form is correct and complete.
  • acknowledges that, by submitting this Satellic Direct Debit Application Form, he/she is bound by the SDD Specific Terms and Conditions, which shall form an integral part of the SDD Addendum that is part of the General Terms & Conditions (User Contract) between Satellic and the User.