Australia On Line Direct Debit Form

Level 4 / 6 Riverside Quay
Southbank, Victoria, 3006
Ph		1300 650 661
Fax:		(03) 9686 1052
ABN:		88 064 289 925

DIRECT DEBIT AUTHORISATION

Simply complete all details below and either FAX on (03) 9686 1052 or MAIL to Australia On Line within 5 days (if form not returned promptly your account may be suspended), Level 4, 6 Riverside Quay, Southbank, Victoria, 3006.

SECTION 1: CUSTOMER DETAILS

Title:
First Name:
Last Name:
Company Name:
Address:
Address:
State:			Post Code:
Phone:			Mobile:
Fax:			Email:

SECTION 2: EXISTING CLIENT DETAILS

Are you an existing client?

YES — Please provide username ......................................................................

SECTION 3: DIRECT DEBIT REQUEST

Name of Financial Institution

Branch

Address of Financial Institution

Account Name (eg. Mrs Joan Smith)

Account Details

BSB Number

Account Number

Name of Account Holder

I / We

Authorise Australia On Line (APCA user ID 068158) to withdraw the funds from the specified bank account to the value of services provided by Australia On Line as prescribed through the Bulk Electronic Clearing System (BECS).

This authorisation is to remain in force in accordance with the terms described in the Australia On Line Customer Service Agreement, which is available for review on the website http://www.australiaonline.net.au/terms.html.
To revoke this authorisation you must cancel at the website http://www.cancel.australiaonline.net.au


Signature:......................................................................	Date:..............................

Please note: The first payment will be debited from your nominated bank account on the first working day of the week after the form has been returned. The amount will be for the pro rata amount for the month you joined. Thereafter you will be billed on the 1st working day of the month for that month in advance.