Direct Debit Request

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

Type

Your Reference *

First Name *

Last Name *

Email *

Mobile No

SMS Reminders

I authorise Ezidebit to remind me of upcoming debits via SMS

Address Line 1 *

Address Line 2

Suburb *

State *

Postcode *

Debit Arrangement

Once Off Debit

Debit Amount

Date

Regular Debits

Debit Amount

Starting

Frequency

Duration

Fees / Charges

One Time Setup Fee

$3.30

Bank Account

$1.25

Optional SMS Reminder

$0.28

Visa/Mastercard

2.2% (min $1.25)

Amex

4.4% (min $1.25)

Failed Payment Fee

$14.80

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

Type

Card Number *

Expiry Date *

Card Holder Name *

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

Ezidebit AU Direct Debit Request (DDR) Service Agreement (Version 1.12)

Please print and retain for your records. This Direct Debit Request Service Agreement (Agreement) forms part of the terms and conditions of
your Direct Debit Request (DDR).

Debiting Your Account
1.  By agreeing to the DDR you authorise Ezidebit Pty Ltd ACN 096 902 813 (Direct Debit User ID number 342190, 342191, 428198) (referred to as Ezidebit)
    to make debits to your nominated account.
2.  The debit will be processed on the next business day after the direct debit date if:
    a. a payment request is received by Ezidebit after Ezidebit's usual cut off time, being 3:00pm Qld time, Monday to Friday;
    b. there is a public or bank holiday on the day when the debit transaction is due to be processed or on any of the following days until the debit is processed.
3.  You authorise Ezidebit to attempt to re-debit any unsuccessful payments. You will also be responsible for any fees and charges applied by your financial
    institution for each unsuccessful debit attempt together with any collection fees, including but not limited to any solicitor fees and/or collection
    agent fee as may be incurred by Ezidebit.
4.  Ezidebit may charge you certain fees (including setup, variation, SMS or processing fees) where applicable under your debit arrangement.

Your Responsibilities
5.  It is your responsibility to:
    a. Ensure that your nominated account can accept direct debits;
    b. Ensure that the details on the DDR are correct, and the bank account has been verified against a recent bank statement;
    c. Ensure that all authorised signatories nominated on the financial institution account to be debited authorise the DDR;
    d. Ensure that there are sufficient cleared funds in the nominated account, as a failed payment fee may be charged by Ezidebit if a debit is returned
       by your financial institution as unpaid;
    e. Advise immediately if the nominated account is transferred or closed or your account details change;
    f. Arrange a suitable payment method if Ezidebit or the Business cancels the drawing arrangements.

Cancelling or Changing Direct Debits
6.  Subject to the terms and conditions of your agreement with the Business, you may cancel, alter or defer the debit arrangement by contacting the Business
    a reasonable time before the date that the drawing is to be made.
7.  You authorised Ezidebit to vary the amount of the payments from time to time upon receiving instructions from the Business of a variation provided for
    within your agreement with the Business. In all other cases, changes to the amounts or dates of a series of direct debits require 14 days' prior notice.
8.  If you believe that there has been an error in debiting your account, you should notify the Business as soon as possible.
    The Business will notify you of its determination and the amount of any adjustment that will be made to your nominated account (if any). Upon receiving
    instructions from the Business, Ezidebit will arrange for your financial institution to adjust your nominated account by the applicable amount (if any).
    Alternatively, you can also contact your financial institution.
9.  You agree that Ezidebit will not be liable for any disputed transactions resulting from the supply or non-supply of goods and/or services by the Business
    and that all disputes will be directed to the Business (as Ezidebit is acting only as an agent for the Business).

Confidentiality
10. We will keep your account details and direct debit records confidential in accordance with Ezidebit's Privacy Policy, except where the disclosure of
    certain information to your financial institution is necessary to enable us to act in accordance with your drawing arrangements.
    We may disclose the information in the event of an alleged incorrect or wrongful debit, in relation to a claim, or otherwise as required by law.

Contact
If you wish to contact Ezidebit about anything relating to this Agreement, you should contact:
Ezidebit
PO Box 3327, Newstead, QLD 4006
Ph: 1300 763 256 Email: support@ezidebit.com.au
https://www.ezidebit.com/en-au/contact

I agree to the Terms and Conditions of the Direct Debit Request and Service Agreement *