Direct Debit Request Form

Request and authority to debit the account named below to pay Nexia Edwards Marshall NT Pty Ltd

Surname or Company Name *

Given Names or ACN/ARBN *

("you") request and authorise Nexia Edwards Marshall NT Pty Ltd (User ID 502047) to arrange for any amount Nexia Edwards Marshall NT Pty Ltd may debit or charge you to be debited through the Bulk Electronic Clearing System from an account held at the financial institution identified below subject to the terms and conditions of the Direct debit request service agreement (and any further instructions provided below).

Insert the name and address of the financial institution at which account is held

Financial institution name *

Address *

Insert details of account / credit card to be debited

Name of account

BSB

Account number

OR

Cardholder name

Card number

Expiry date

CVV

Acknowledgement

By signing this Direct debit request you acknowledge having read and understood the terms and conditions governing the debit arrangements between you and Nexia Edwards Marshall NT Pty Ltd as set out in this request and in your Direct debit request service agreement.

Select an option by ticking a box

The maximum amount to be delivered at any one time is

$

Amount in words

The first debit may be made on

First debit date

and at

Frequency

intervals after that.

Debits may be made fourteen days after the issue of a billing advice.

This agreement is to end by

or after (number of payments)

Insert your address and signature

Address

Email address

Signed *

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Date *

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