I/we request and authorise Trinity Telecom (Direct Debit User ID 321365) until further notice, to arrange payment of
my Trinity Telecom account as per details above by debiting my/our account on a monthly basis.
Financial Institution Account details are: FI Name
FI Branch Name
BSB
Account No
Account Name
I/we acknowledge that this Direct Debiting arrangement is governed by the terms of the Direct Debits Service
Agreement received from you.
Signature
Date
Name
Signature
Date
Name
Are two signatures required if joint or business account?
DIRECT DEBIT REQUEST
via Financial Institution
Cardholder Name
Card Number
Expiry Date
Signature
I/we acknowledge that this Direct Debiting arrangement is governed by the terms of the Direct Debits Service
Agreement received from you.
Account Number (If Known)
Customer Name:
Company Name (If Applicable):
Address:
Direct Debit Service Agreement March 2009
Trinity Telecom Pty Ltd ABN 49 108 322 452
Version 1.1
