Complete this form if you would like to register and store Payments cannot be made to credit card, loan or mortgage your bank account details for the purpose of making accounts. payments to you. 6). Name of Bank, Building Society or Credit Union You can also register your bank account details: _______________________________________________ By calling xxxxxxxx In person at your ___________________________ Branch where your account is held Online At www.bankwebsite.com _______________________________________________ Assistance Branch Number (BSB) If you need help completing this from call _____________ or visit www.bankwebsite.com - Account Number Lodgment _______________________________________________ Send this completed form to: _______________________ Account Held in the Names of: YOUR DETAILS _______________________________________________ _______________________________________________
1). Bank card Number CONSENT
- - Reference No. People over 14 have to sign to indicate consent for their payments. 2). Dr Mr Mrs Miss M s Date:
Family Name: ________________________________ ____/_____/_________
Signatures First Given Name: _____________________________ Date:
3). Date of Birth: ____/____/__________ ____/_____/_________