Direct Debit Request (DDR)

A request and authorise Care Park Pty Ltd user ID 318266 to arrange, a debit to your nominated account to pay for car parking. This debit or charge will be arranged by Care Park Pty Ltd financial institution and made through the Bulk Electronic Clearing System (BECS) from your nominated account and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

Surname or Company(Required)

Last

Your Given names or ABN/ARBN

Any amount Care Park Pty Ltd has deemed payable by you

(Tick if applicable)

Or - The amount specified in the invoice we have sent you, for payment on a due date

(Tick if applicable)

Frequency

Amount

End Date

Address(Required)

Street Address State / Province / Region ZIP / Postal Code

Email(Required)

Mobile(Required)

By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have confirm that:(Required)

Yes

- you are authorised to operate on the nominated account; and - you have understood and agreed to the terms and conditions set out in this Request and in your Direct Debit Request Service Agreement.

Consent

I agree.

Surname or Company

Last

Second account signatory (if required)

Date

Address(Required)

Street Address State / Province / Region ZIP / Postal Code

Signing for a company

Last

You must be authorised to sign on behalf of the company AND you must have authority to operate the Company’s bank account.

Consent