Direct Debit Payment Authority: Complete form

Surname (or Business/Trust name) *

Given Name(s) (optional)

Or full contact name if completing for a business or trust.

Telephone *

Email *

We will send you a confirmation letter within 5 business days. Please enter the address you would like us to send the confirmation letter to *

Bank Account Number from which payments are to be made *

- - -

BankBranchAccount NumberSuffix

Name of Bank Account *

Bank *

Branch *

Town/City *

I/We authorise you until further notice in writing to debit my/our account with all amounts which: OPOTIKI DISTRICT COUNCIL
(herein referred to as the Initiator) the registered Initiator of the above Authorisation Code, may initiate by Direct Debit. I/We acknowledge and accept that the bank accepts this authority only upon the conditions as detailed in the Conditions of this Authority to accept Direct Debits *

Signatory *

Type your full legal name (typing your legal name is acceptable by online application). This will also indicate to us that you have full authority on the account. If required a hard copy of this document can be made available for signing.

Second Signatory (if required) (optional)

Type your full legal name (typing your legal name is acceptable by online application). This will also indicate to us that you have full authority on the account.

Date (optional)

Direct Debit Payment Authority

Customer details

To: The Bank Manager

AUTHORITY TO ACCEPT DIRECT DEBITS (Not to operate as an assignment or agreement)

AUTHORISATION CODE 0112495