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

I request and authorise Fat Zebra ACN 154 014 785, APCA User ID Number 502574 to arrange, through its own financial institution, a debit to the nominated account below any amount the Australian Education Union SA Branch has deemed payable.

By signing this Direct Debit Request, you have understood and agreed to the terms and conditions governing the debit arrangements set out in this Request and in your Direct Debit Request Service Agreement.

Financial Institution Name

BSB *

xxx-xxx

Account Name *

(name of account holder)

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.