The Pine Rivers Golf Club

Application For Direct Debit Request (DDR)

YOUR DETAILS :

Title:

Customer Name:

Phone Number:

Address :

Email:

State :

Postcode :

SCHEDULE

Up Front Fee (1st Payment)

Date Paid

Date of First Payment:

Frequency Monthly

Amount:

Amount of each debit

MINIMUM Number of Payments: 12 Payments

If the scheduled date is not a banking day, the debt will take place on the next banking day.

CHEQUE / SAVINGS ACCOUNT OR CREDIT CARD AUTHORISATION

I/We request Pine Rivers Golf Club Inc (36 964 264 552) to arrange for funds to be debited from my/our nominated account or credit card.

Financial Institution:

Branch:

Account Name:

BSB No.

Account No.

Card :

MASTERCARD

VISA

OTHER

Credit Card Number:

Expiry Date:

Cardholder Name:

CONTRACT TERMS

Please note that this contract is for a MINIMUM term of 12 payments. You are required to make the payments for the minimum term regardless of your circumstances. Your payments will continue indefinitely after the minimum term in accordance with your contract unless you contact us and request payments to stop at the end of the minimum term. Please ensure that you have adequate funds available to meet your payments as the fee for failed direct payments is currently $10.00.

I hereby agree to the terms of the contract for payment of Pine Rivers Golf Club membership fees.

Verification code

Please enter the letters or digits