Regular Payment Request Form - Tralee Credit Union Ltd.
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1REGULAR PAYMENT REQUEST FORM
Member Name
Account No.
I ____________________ hereby authorise and request you to
set up
amend
a debit on the above account and to credit the below account until further
notice in writing. It shall be understood the Credit Union shall not be under any
liability for damages or loss caused by omission to make these payments.
PAYEE NAME
Name of the person or organisation you
are paying
PAYMENT REFERENCE
This will appear on the bank statement
of the organisation you are paying
BANK SORT CODE
The bank code of the organisation you
are paying
BANK ACCOUNT NO.
The account number of the organisation
you are paying
AMOUNT
FREQUENCY
WEEKLY
[
]
FORTNIGHTLY
[
]
(Please tick as appropriate)
MONTHLY
[
]
Start Date
End Date
Member
Print
Signature
Name
Staff Signature
Print
Name
Date
Amended by
Checked by
CANCELLATION
I wish to cancel my Regular Payment Request with effect from
____________________ (date of last payment request)
Member Signature ________________________ Date _______________
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