You are about to create a Direct Debit Request for Some Company 3.5

Customer Details

Please enter your details, including the reference number given to you

Debit Arrangement

You may enter one or both of the once off and regular debit arrangements

Once Off Debit

Regular Debits

One Time Setup Fee


Bank Account


Optional SMS Reminder



2.2% (min $1.25)


4.4% (min $1.25)

Failed Payment Fee


Payment Method

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Payments will appear on your statement as Some Company 3.5

I / We authorise Ezidebit Pty Ltd ACN 096 902 813 (User ID No 165969) to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System (BECS) in accordance with the Debit Arrangement stated above and this Direct Debit Request and as per the Ezidebit DDR Service Agreement (Ver 1.9) provided.

Service Agreement

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