Direct Debit Form (Page 2 of 2) in pdf

ABN: 67 096 902 813

I/We hereby authorize Ezi Debit Australia Pty Ltd (ACN: 096 902 813) Direct Debit User ID number 165969 (herein referred to as Ezi Debit)

to make periodic debits on behalf of the “Business” as indicated on the front of this Direct Debit Request (herein referred to as the Business)

I/We acknowledge that Ezi Debit is acting as a Direct Debit Agent for the Business and that Ezi Debit does not provide any goods or services

and has no express or implied liability in regards to the goods and services provided by the Business or the terms and conditions of any

agreement with the Business.

I/We acknowledge that the debit amount will be debited from my/our account according to the terms and conditions of the agreement with the

Business.

I/We acknowledge that bank account and credit card details have been verified against a recent bank statement to ensure accuracy of the details

provided. If uncertain you should contact your financial institution.

I/We acknowledge that is is my/our responsibility to ensure that there is sufficient cleared funds in the nominated account by the due date to

enable the direct debit to be honoured on the debit date. Direct debits normally occur overnight; however transactions can take up to three (3)

business days depending on your financial institution. I/We acknowledge and agree that sufficient funds will remain in the nominated account

until the direct debit amount has been debited from the account and that if there are insufficient funds available, I/We agree that Ezi Debit will

not be held responsible for any fees and charges that may be charged by your financial institution.

I/We Acknowledge that there may be a delay in processing if:

1) There is a public or bank holiday on the day, or any day after the debit date

2) A payment request is received by Ezi Debit on a day that is not a Banking Business Day

3) A Payment request is received after normal Ezi Debit cut off times, being 4pm QLD time Monday to Friday.

Any payments that fall due on any of the above will be processed on the next business day.

I/We authorise the Business to vary the amount of the payments from time to time as provided for within the Business agreement. I/We

authorise Ezi Debit to vary the amount of the payments upon instructions from the Business. I/We do not require Ezi Debit to notify me/us of

such variations to the debit amount.

I/We acknowledge that the business is to provide 14 days notice if proposing to vary the debit amounts.

I/We acknowledge that variations to the debit arrangement will be directed to the Business.

I/We acknowledge that any request to stop or cancel the debit arrangement will be directed to the Business.

I/We acknowledge that any disputed debit payments will be directed to the Business. If no resolution is forthcoming you are advised to contact

your financial institution.

I/We acknowledge that if a debit is returned by my/our financial institution as unpaid, I/We will be responsible for any fees and charges for

each unsuccessful debit in addition to any financial institution charges and collection fees, including and not limited to any solicitor fees and

collection agent fees appointed by Ezi Debit.

I/We authorise Ezi Debit to attempt to re-process any unsuccessful payments as advised by the Business.

I/We acknowledge that if specified by the Business, a setup, variation, SMS or processing fees may apply as instructed by the Business.

Credit Card Payments

I/We acknowledge that “Ezi Debit Australia” will appear as the business name for all payments from credit card. I/We acknowledge and agree

that Ezi Debit will not be held liable for any disputed transactions resulting in the non supply of goods and/or services and that all disputes will

be directed to the business as Ezi Debit is acting as a 3

party payment provider. I/We Acknowledge and agree that in the event that a claim is

made, Ezi Debit will not be liable for the refund of any funds.

Ezi Debit will keep your information about your nominated account at the financial institution private and confidential unless this information

is required to investigate a claim made in it relating to an alleged incorrect or wrongful debit, or otherwise required by law. Further information

relating to Ezi Debit’s Privacy Policy can be found at

I/We authorise:

1) The Debit User to verify details of my/our account with my/our financial institution

2) The Financial Institution to release information allowing the Debit User to verify my/our account details.

Po Box 5839

West End, QLD 4101

Ph: (07) 3255 1733

Fax: (07) 3255 3733

Direct Debit Form Page 2

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