Direct Debit Request

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Request and Authority to debit the account named below to pay
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Request and Authority Your surname or company nt*" ( i'-{Fi{
to debit
Your Given names or ABN/ARBN f&f i Q L I G.t U C 4
.'oyou"

request and authorise LAKE$ GRAMMAR - AN ANGLIcnn Scroor, 374704 to

anange, through its own financial institution, a debit to your nominated account
any amount LAKES GRAMMAR - AN ANGLTCAN ScHooL, has deemed payable
by you.

This debit or charge will be made through the Bulk Electronic Clearing System
(BECS) from your account held at the financial institution you have nominated
below and will be subject to the terms and sonditions of the Direct Debit Request
Service Agreement.

Insert the name and f inancial institution name € CRCE

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address of financial
Address
institution at which
account is held

Insert details of Name/s on account a cftr<A-c4

account to be debited
BSB number (Mu$ be 6 Disib)

Account number rj1rt-r8 14 lri \tot?r

Acknowledgment By signing and/or providing us with a valid instruction in respect to yoar Direct
Debit Request, you have understood and agreed to the terms and conditions
governing the debit arrangements between you and LAKES GRAMMAR - AN
ANGLTcAN Sctrool as set out in this Request and in your Direct Debit Request
SeryiceAgreement. r a_
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Payment Details d The first debit of gil--iufA{-ade on ----- 1:-.---12020 and at
weekly/fu,rt*ightlyhonthly intervals after that.

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Insert your signature
Signature
and address
(If signing for a , sign and print full name and capacity for signing
eg. director)

Address
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Date il'rs t}oaQ
Version Control (05i05)