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Request for Bank Account Details

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                                                                  ABN: 59 217 957 665
                                                                   23-25 Chelmsford Place Leeton NSW 2705
                                                                     Tel: (02) 6953 0911 Fax: (02) 6953 3337
                                                                       Email: council@leeton.nsw.gov.au



                       Request for Bank Account Details
Leeton Shire Council has the facility to credit payments direct to your nominated
bank account. Please complete this form and return by mail or fax.


Creditor Name: ............................................................................................................

Address: ......................................................................................................................

          ..........................................................................................................................

          ..........................................................................................................................

Postcode: ....................................................................................................................

ABN No.: .....................................................................................................................

Phone No.: ..................................................................................................................

Fax No.: ......................................................................................................................

Email Address: ............................................................................................................

Bank BSB: ...................................................................................................................

Bank Account No.: .......................................................................................................

Bank Account Name: ...................................................................................................

Contact Details: ...........................................................................................................

Signed: ........................................................................................................................

Position: ......................................................................................................................

Date: ...........................................................................................................................


Thank you

				
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