NAME OF BANK ACCOUNT :
CUSTOMER TO COMPLETE BANK/BRANCH NUMBER AND
ACCOUNT NUMBER AND SUFFIX OF ACCOUNT TO BE DEBITED
Bank
Branch Number
Account Number
AUTHORITY
TO ACCEPT
DIRECT DEBITS
(Not to operate as an
assignment or agreement)
BANK
BRANCH
TOWN/CITY
AUTHORISATION CODE
0 1 0 0 4 6 6
DATE : .......................................
I/We authorise you until further notice in writing to debit my/our account with you all amounts for which EFTPOS New Zealand
Limited (hereinafter referred to as the Initiator), the registered Initiator of the above Authorisation Code may initiate by Direct
debit.
I/We acknowledge and accept that the Bank accepts this authority only upon the conditions listed on the reverse of this form.
NAME OF ACCOUNT:
(CUSTOMER TO COMPLETE)
AUTHORISED SIGNATURE(S):
CUSTOMER PHONE NUMBER:
Approved
0046
03 2013
FOR BANK USE ONLY
Original: Forward to and retain at Paying Bank.
Copy: Forward to Merchant.
BANK STAMP
41/70 7630A
DATE
RECEIVED:
RECORDED
BY:
CHECKED
BY:
Direct Debit Authority Form
Please complete this Direct Debit Authority and return to EFTPOS New Zealand by email, fax or post.
Fields marked with an X are compulsory. If you are having any problems completing this form,
please call 0800 EFTPOS, 0800 338 767.
X
X
X
X
X
X
0800 EFTPOS
www.eftpos.co.nz
sales@eftpos.co.nz
0800 333 124
PO Box 3457, Wellington 6140
Please complete this Direct Debit Authority and return to EFTPOS New Zealand by email, fax or post:
*Please include a encoded deposit slip to ensure your number is loaded correctly.
X
EFTPOS New Zealand Contract Number:
X
EFTPOS New Zealand Reference Number:
OR
(Also referred to as RID or Merchant Number)
Bank Copy
click to sign
signature
click to edit
Fax form to: 0800 333 124
CONDITIONS OF THIS AUTHORITY
1. The Initiator:
a) Undertakes to give notice to the Acceptor of the commencement date, frequency and amount at least 10 calendar days before
electronic means and SMS where the Customer has provided prior written consent (including by electronic means including
SMS) to communicate electronically).
Where the Direct Debit system is used for the collection of payments which are regular as to frequency, but variable as to
amounts, the Initiator undertakes to provide the Acceptor with a schedule detailing each payment amount and each payment
date.
In the event of any subsequent change to the frequency or amount of the Direct Debits, the Initiator has agreed to give advance
notice at least 30 days before the change comes into effect. This notice must be provided in writing (including by electronic
means and SMS where the Customer has provided prior written consent (including by electronic means including SMS) to
communicate electronically.
b) May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no further Direct
Debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future
payments by notice in writing to me /us.
c) May, upon receiving an “authority transfer form” (dated after the date of this authority) signed by me/us and addressed to
a bank to which I/we have transferred my/our bank account, initiate Direct Debits in reliance of that transfer form and this
2. The Customer may:
a) At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the
Initiator.
b) Stop payment of any Direct Debit to be initiated under this Authority by the Initiator by giving written notice to the Bank prior to
the Direct Debit being paid by the Bank.
c) Where a variation to the amount agreed between the Initiator and the Customer from time to time to be Direct Debited has
been made without notice being given in terms of clause 1(a) above, request the Bank to reverse or alter any such Direct Debit
initiated by the Initiator by debiting the amount of the reversal or alteration of Direct Debit back to the Initiator through the
Initiator’s Bank. PROVIDED such request is made not more than 120 days from the date when the Direct Debit was debited to
my/our account.
3. The Customer ackn
owledges that:
a) This Authority will remain in full force and effect in respect of all Direct Debits passed to my/our account in good faith
notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by
the Bank.
b) In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to
my/our account.
c) Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank
except in so far as the Direct Debit has not been paid in accordance with this Authority. Any other disputes lies between me/us
and the Initiator.
d) Where the Bank has used reasonable care and skill in acting in accordance with this authority, the Bank accepts no
responsibility or liability in respect of:
- the accuracy of information about Direct Debits on Bank statements.
- any variations between notices given by the Initiator and the amounts of Direct Debits; and
e) The Bank is not responsible for, or under any liability in respect of the Initiators failure to give notice in accordance with 1(a)
nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies
between me/us and the Initiator.
f) Notice given by the Initiator in terms of clause 1(a) to the debtor responsible for the payments shall be effective. Any
communication necessary because the debtor responsible for payment is a person other than me/us is a matter between me/
us and the debtor concerned.
4. The Bank may:
a) In its absolute discretion conclusivel
y determine the order of priority of payment by it of any monies pursuant to this or any
other Authority, cheque or draft properly signed by me/us and given to or drawn on the Bank.
b) At any time terminate this Authority as to future payments by notice in writing to me/us.
c) Charge its current fees for this service in force from time-to-time.
d) Upon receipt of an “authority to transfer form” signed by me/us from a bank to which my/our account has been transferred,
transfer to that bank this Authority to Accept Direct Debits.