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

Please enter your regular debit arrangement

Regular Debits

One Time Setup Fee

$3.30

Bank Account

$1.25

Optional SMS Reminder

$0.28

Visa/Mastercard

2.2% (min $1.25)

Amex/Diners

4.4% (min $1.25)

Failed Payment Fee

$11.90

Payment Method

Please choose a method of payment

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

*This is a preview page only, no payments can be taken on this page.