powerclub

ABN 71 603 346 836

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Direct Debit Form

I/We request to arrange for funds to be debited from my/our nominated account at the financial institution as per
schedule below. This debit or charge will be made through the Bulk Electronic Clearing System (BECS) with User ID 531666,
from my/our account held at the financial institution I/we have nominated below and will be subjected to the Direct Debit
Credit Terms and Conditions.

1034196 Kai Chan

Account Number: ....................................... Customer Name: ........................................................................................

3 Charles Street Werribee VIC

Address: ............................................................................................................................ State: ................................

3030 0422088488
Postcode: ................................................. Phone Number: ............................................................................................

ericchan87@gmail.com
Email Address ................................................................................................................................................................

Schedule: Payments will be debited on the due date. If the due date falls on a holiday, the direct debit charge will take
place on the next business day.

Option 1: Bank Account Details

Note: Direct Debiting is not available on all accounts. If in doubt, refer to your financial institution.

Kai Chan Abbotsford

Account Name: ................................................................... Bank Branch: .................................................................... .

013200 565609358
BSB Number: ..................................................................... Account Number: .................................................................

Option 2: Credit Card Details

Ovisa
✔ D Mastercard □ AMEX DDiners

Name on Credit Card: ...................................................................................................................................................

Credit Card Number: ....................................................................................................................................................

Expiry Date: ........................................................................ CCV: ..................................................................................

Acknowledgement: I/We have read and agreed to the Direct Debit Credit Terms and Conditions attached. I/We
request that this Direct Debit Credit Request remain in force until cancelled, deferred or otherwise altered in
accordance to the Direct Debit Credit Terms and Conditions. I/we also confirm that the account/credit card
details set out above, are correct and this Direct Debit Credit Request is signed by the number of authorised.

Signature(s) Signature(s)
Kai Chan Kai Chan

12 01 2020 12 01 2020
Date: ................. / .................... / .................... Date: ................. / .................... / ....................

Address: The Hub Southern Cross, Level 2, 696 Bourke Street, Melbourne VIC 3000 ; Telephone: 1300 294 459 ; Email: info@powerclub.com.au