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

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 Credit Card Details

Please choose a method of payment. To request a standard paper Direct Debit Authority form to sign and return, please contact the Business

Please enter your credit card details

Payments will appear on your statement as EZI*Some Company 3

By agreeing to this form, I / We authorise Ezidebit, acting on behalf of the Business, to debit payments from my specified Credit Card above, and I / we acknowledge that EZI*Some Company 3 will appear as the merchant on my credit card statement. Furthermore, I / we agree to reimburse and indemnify Ezidebit for any successful claims made by the Card Holder through their financial institution against Ezidebit.

Service Agreement

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