You are about to create a Direct Debit Request for UGA-540 Emergency Medical Services
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You may enter one or both of the once off and regular debit arrangements
One Time Setup Fee
$0.00
Bank Account
Optional SMS Reminder
Visa/Mastercard
0.00%
Amex
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 bank account details
Please enter your credit card details
Payments will appear on your statement as UGA540EMERGENCYM
I / We authorise Ezidebit Pty Ltd ACN 096 902 813 (User ID No 342190, 342191, 428198) to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System (BECS) in accordance with this Direct Debit Request.
Payments will appear on your statement as EZI*UGA540EMERGENC
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*UGA540EMERGENC 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.
*This is a preview page only, no payments can be taken on this page.
Approved
DDR Service Agreement(Ver )
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