Fillable Printable TV Licence Application Form
Fillable Printable TV Licence Application Form
TV Licence Application Form
Application for the purchase of a TV Licence
by Direct Debit from a Bank Current Account
Part 1 of 2
TV Licence Details (* denotes mandatory fields)
TV Licence Account Reference Number
Full name on the TV Licence
Only one name may be on the TV Licence
*
Full Address the TV Licence is to cover
*
Postal Address if different
Contact Phone Number
*
TV Licence Holder Declaration
I hereby agree to payment of my TV Licence by Direct Debit. I accept that it is my responsibility and undertake to ensure that my
TV licence remains valid at all times. Non-receipt of the full payment will result in the revocation of the TV Licence and a
replacement TV Licence must be purchased in full or I may be prosecuted under the Broadcasting Act 2009.
TV Licence Holder signature *_______________________________ Date *_____________________________
An Post TV Licence reserves the right to decline a Direct Debit mandate as a TV Licence payment option.
Required Documentation
You are required to submit a recent bank statement with this Direct Debit application. The bank statement must show the BIC, IBAN and the
full name and address of the Bank Account Holder. You should ensure that financial transactions on your bank statement are fully masked or
removed before you attach it to your application. All bank statements are destroyed once the first successful payment has gone through.
Terms & Conditions and Payment Option
This Direct Debit Agreement will remain in force on a year to year basis. Any changes to the TV Licence fee will apply to all TV
Licences purchased, or future TV Licence fees payable, after the date on which the fee comes into force. An Post will notify you, by
post, on an annual basis of the amounts due to be debited from your Bank Account. See www.tvlicence.ie. Should you wish to change
the frequency option for the payment of your next TV Licence, you must complete a new application form and send it to your local TV
Licence records office 16 days before your current TV Licence is due to expire. You may only cancel your direct debit instruction in the
month your TV Licence is due to expire after full payment has been made.
The TV Licence fee is payable on year to year basis under the Broadcasting Act 2009 or under subsequent encompassing legislation.
Under this Direct Debit Agreement, you are legally obliged to pay the full cost of the TV Licence. You are legally required to continue
paying for your TV Licence during its validity period regardless of whether you discard the TV Set, are awarded a Department of Social
Protection TV Licence, leave the country or move to another premises already covered by a TV Licence or for any other circumstances.
You are required to inform An Post TV Licences if you are changing the bank account number for the payment of the TV Licence.
The onus is on the Bank Account Holder to ensure the Direct Debit Instruction remains in operation for the payment of the TV Licence.
The TV Licence fee may be paid by an annual debit or by instalments. Please tick the box indicating the frequency of direct debiting
that you require, annually, bi-annually, quarterly or monthly. Where a direct debit mandate is being set-up in respect of a renewal TV
Licence, the existing expiry date of the TV Licence will remain unchanged and any arrears due to the date of the set-up will be
collected in the first instalment.
Debit Frequency Annual Bi-annually Quarterly Monthly
Bank Account Holder Declaration
I hereby instruct my Bank to pay Direct Debits from my account at the request of An Post TV Licence. The amounts to be debited
may be variable. I shall duly notify An Post TV Licence in writing if I wish to cancel this instruction but shall only do so upon
completion of payment for the current TV Licence. I agree to the terms and conditions of paying the TV Licence fee by Direct Debit
from my Bank Current Account and I fully accept that this Direct Debit Agreement is legally binding.
Bank Account Holder signature * ___________________________ Date *______________________________
CHECKLIST:
Part 1 - Application for the purchase of a TV Licence and Part 2 - SEPA Direct Debit Mandate forms MUST be completed
Incomplete forms or those without an accompanying bank statement (COPY – non returnable) will not be processed.
We advise that you retain a copy of this Direct Debit Agreement.
Banks may refuse to accept instructions to pay Direct Debits from some types of bank accounts
Please complete and return to your local TV Licence Records Office. See www.tvlicence.ie
Information provided to An Post TV Licence is securely and safely held and processed by An Post TV Licence in accordance with
relevant legislation, including the Data Protection Acts 1988-2003.
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
