EmailMe Form - M'Ship: Direct Debit Update

AEU Member No.

Employee ID

Date of Birth

DD / MM / YYYY

Surname *

Given Name *

Postal Address

Home Phone

Mobile Number

Workplace Name

Email

Classification *

Tier or Step/Level

eg Tier 9; SSO1/6

Fraction of Time

DIRECT DEBIT REQUEST

By signing this document, I/We authorise the Australian Education Union (South Australian Branch), Debit User Number 015604, the Debit User, to debit my/our account, detailed in the Schedule below, every fortnight with any amount, through the Direct Debit System, I/we must pay you when due under the arrangement between us.

This authority is to remain in force until further notice.

This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement

The Schedule:

Financial Institution Name

Financial Institution Address

Account Title *

(name of account holder)

BSB *

xxx-xxx

Account Number *

Signature *

Clear

Use your mouse to sign this form. Click in the grey area below the yellow highlighted line and the word 'signature'. Click and hold the mouse button as you sign.