Direct Debit Request Form
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1
2
3Direct Debit Request
Request and Authority to debit the account named below to pay
Peter Lees Real Estate
Request and Authority
to debit
Your Surname or company name ______________________________
Your Given names or ABN/ARBN ______________________________ “you”
Request and authorise
Peter Lees Real Estate
to arrange, through its own
financial institution, a debit to your nominated account any amount
Peter Lees
Real
Estate, has deemed payable by you.
This debit or charge will be made through the Bulk Electronic Clearing System
(BECS) from your account held at the financial institution you have nominated
below and will be subject to the terms and conditions of the Direct Debit Request
Service Agreement.
Insert the name and
Financial Institution Name ______________________________
address of financial
institution at which
Address ____________________________________________
account is held
____________________________________________
Insert details of
Name/s on account ___________________________________
account to be debited
BSB Number (Must be 6 Digits) |__|__|__|-|__|__|__|
Account Number
|__|__|__|__|__|__|__|__|__|
Acknowledgement
By signing and/or providing us with a valid instruction in respect to your Direct
Debit Request you have understood and agreed to the terms and conditions
governing the debit arrangements between you and
Peter Lees Real Estate
as
set out in this Request and in your Direct Debit Request Service Agreement.
Insert your Signature
and address
Signature _______________________________________
(if signing for a company, sign and print full name and capacity for signing eg. Director)
Address ____________________________________________
____________________________________________
Date
___ / ___ / ___
Second account
Signature _______________________________________
signatory (if required)
(if signing for a company, sign and print full name and capacity for signing eg. Director)
Address ____________________________________________
____________________________________________
Date
___ / ___ / ___
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Parent category: Financial