Direct Debit Request Form - DOC by BO8sFFIT

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									              Royal Brighton Yacht Club Inc.
              ABN 247 682 10 467
                                                                             Direct Debit Request
                        Request and Authority to debit the account named below to pay
                                      Royal Brighton Yacht Club Inc.
Request and Authority to Surname or company name _______________________________________
debit
                         Given names or ACN/ARBN __________________________________(“you”)

                             request and authorise Royal Brighton Yacht Club Inc.[Debit User Identification
                             Number 199041] to arrange, through its own financial institution, for any amount
                             Royal Brighton Yacht Club Inc may debit or charge you to be 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.

Insert the name and          Financial institution name             ________________________________________
address of financial
                             Address         _______________________________________________________
institution at which
                                             _______________________________________________________
account is held

Insert details of account    Name of account                _____________________________________________
to be debited
                             BSB number                     |___|___|___| - |___|___|___|

                             Account number                 |___|___|___|___|___|___|___|___|___|
Or Credit Card
                             Credit Card number                                   Exp. Date |___|___|___|___|
Visa / Mastercard /Amex
                             |___|___|___|___|-|___|___|___|___|-|___|___|___|___|-|___|___|___|___|

Acknowledgment               By signing this Direct Debit Request you acknowledge having read and understood the
                             terms and conditions governing the debit arrangements between you and Royal
                             Brighton Yacht Club Inc. as set out in this Request and in your Direct Debit Request
                             Service Agreement.

Payment Details                    Any outstanding amount on my account.
                                   Maximum amount to be debited at any one time for Membership & Bar Tabs
                             $ |___|___|___| - |___|___| ________________________________________
                                                                            (amount in words)

                                   The maximum amount to be debited at any one time for Membership only:
                             $ |___|___|___| - |___|___| ________________________________________
                                                                            (amount in words)

                             The     first   monthly debit          may     be    made      in       ___     /   ___     (month/year).


Insert your signature and    Signature _______________________________________________________
address                             (If signing for a company, sign and print full name and capacity for signing eg. director)

                             Address         _______________________________________________________
                                             _______________________________________________________
                             Date            ___ / ___ / ___

								
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