Direct Debit Request for Ipswich Hospital Foundation - Fit4Life Memberships

Customer Details
Please enter your details
Debit Arrangement
Please enter your regular debit arrangement.

Regular Debits

Fees / Charges
One Time Setup Fee $0.00 Visa/Mastercard 0.00% Optional SMS Reminder $0.00
Bank Account $0.00 Amex/Diners 0.00% Failed Payment Fee $21.90
Payment Method
Please choose a method of payment.

Payment Method

Payments will appear on your statement as FIT4LIFE

I / We authorise Ezidebit Pty Ltd ACN 096 902 813 (User ID No 165969) to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System (BECS) in accordance with the Debit Arrangement stated above and this Direct Debit Request and as per the Ezidebit DDR Service Agreement (Ver 1.9) provided.

Service Agreement