* Denotes mandatory field.
Financial Institution Name*:
Name/s on account*:
Frequency* (please note debits occur on the 16th of the month):
Start month (optional):
Amount to be debited (AUD)*:
If other, please specify amount to be debited:
Please note: Recurring debits continue until further notice. For all correspondence and changes to frequency, please Contact Us.
I/We request and authorise CQ Rescue (Direct Entry User ID 447949) to arrange, through its own financial institution, to debit my/our nominated account, any amount CQ Rescue has deemed payable by me/us.
I/We understand the debit amount will be calculated from the Debit Arrangement I/we have agreed to by completing this form.
I/We acknowledge this debit or charge will be made through the Bulk Electronic Clearing System (BECS) from my account held at the financial institution I/we have nominated and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.
By submitting this form you agree to the above authorisation and the Central Queensland Helicopter Rescue Service Ltd Direct Debit Request Service Agreement.
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