Direct Debit Form | St Thomas Syro Malabar Mission Bendigo

Direct Debit Request

DIOCEASE OF SANDHURST
DEVELOPMENT FUND
172-174 McCrae Street (PO BOX 201)
Bendigo Victoria 3552
Telephone: (03) 5445 3606
Fax: (03) 5441 8278

Action *

New Request

Alteration

Cancellation

Section 1: Details of Account Authority

I/We (Name of Customer/s) *

Request and Authorise Diocesan Development Fund, Debit used Identification number 268894 to arrange, through its own financial institution, for any amount Diocesan Development Fund may debit or charge you debited through the Bulk Electronic Clearing System from an account held at the financial institution identified below and Paid to the Debit User, subject to the terms and conditions of the Direct Debit Request Service Agreement.

Section 2: Details of Account to be Debited

Branch Location *

Name of Financial Institution *

BSB No *

Account No *

Account Name *

Section 3: Payment Details

By Signing this Direct Debit Request You acknowledge having read and understood the Terms and Conditions governing the debit arrangements between you and the Diocesan Development Fund as set out in your Direct Debit Request Service Agreement.

Payment Frequency *

Weekly

Fortnightly

Monthly

Quarterly

Once Only

No. of Installments *

Start Payment Date *

Amount Of *

AUD

End Payment Date *

Section 4: Authority

Sign Here * Clear

Date *

Terms & Conditions

The above request has been arranged through the Diocese of Sandhurst Development Fund, On behalf of ST THOMAS SYRO-MALABAR MISSION BENDIGO.

By submitting this form You have given St Thomas Syro Malabar Mission Bendigo, the right to keep a record of the above information. All information provided will be kept private and secure.