Direct Debit Request Authority (Debtors

DIRECT DEBIT REQUEST AUTHORITY

DEBTORS - GENERAL

For further information or questions regarding this form, please contact Council via 9911 6555.

Applicant Details

Business Trading/Customer Name *

Debtor Account/Application Number(s) *

Please choose one *

New ApplicationReplace Existing Application

Details of the Account to be debited – SAVINGS OR CHEQUE ACCOUNT ONLY

Name of Financial Institution: *

Branch: *

Name(s) of Account Holders: *

BSB Number: *

Account Number: *Do not enter credit card number

Payment Details

I/We wish to nominate the amount of deduction as per the invoice total on the invoice due date.

*Please email debtors@canadabay.nsw.gov.au should you wish to discuss other schedule options.

Additional Comments/Instructions

Applicant declaration

I authorise and request City of Canada Bay Council (Debit Use ID Number 207021) until further notice in writing, to debit to my account, as described in the schedule above, any amount which the City of Canada Bay may debit or charge me through the Bulk Electronic Clearing System (BECS). I have read your service agreement and acknowledge its terms and conditions.

Applicant Signature *

Draw signature|Type signatureClear

Date signed *