AUTHORITY TO ACCEPT DIRECT DEBITS
(Not to operate as an assignment or agreement)
Name of account to be debited
Account details:
Bank Branch
Account Number
Suffix
AUTHORISATION CODE
To: The Manager, (Please Print full Postal Address Clearly for Window Envolope)
Date
Bank Branch
Address (P O box)
Town/City
I/We authorise you until further notice in writing to debit my/our account with all amounts which
BOUTIQUE BODY CORPORATES LIMITED
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.
Information to appear to appear in my/our bank statement
PAYER PARTICULARS
PAYER CODE
PAYER REFERENCE
NAME OF ACCOUNT
AUTHORISED SIGNATURE(S)
For Bank Use Only
BANK STAMP
Date | Recorded | Checked |
Received: | By: | By: |