Conditional Direct Debit Request Form
Payor Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Student Details
*
BSB
*
Account Number
*
Debit Amount ($)
*
Debit Amount ($)
*
Nominate own amount
Contact me with a recommended amount
Nominated Direct Debit amount
Frequency of Debits
*
Weekly
Fortnightly
Monthly
First Payment Date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
By signing this form, I/we authorise Lighthouse Christian School Ltd (ABN 43 645 404 735) to debit my/our account - detailed in the schedule above - through the Direct Debit System which I/we must pay under the agreement between us and in accordance with the School's Direct Debit Request Service Agreement. This authority is to remain in place until the account is paid in full.
Signature
*
Date Signed
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
Should be Empty: