Direct Debt Customer Authority Form

I/We

Authorise RABBIT INTERNATIONAL PTY LTD (Rabbit Net/Tel)

to arrange for funds to be debited from my/our banking or financial institution account below. This authorisation is to remain in force in accordance with Rabbit International's terms and conditions for the purpose of billing of any amounts that are owed to Rabbit International as they become payable.

BANKING DETAILS    
Name of Financial Institution (Bank)  
Address of Financial Institution (Bank)  
Account Holder's Name (The name on the account at the Bank)
BSB Number: (your BSB must contain 6 digits)
Account Number: (Your account number may only be a maximum of 9 digits and cannot contain any letters)

Note: If you are unsure of your correct BSB or Account Number then please contact your Bank or check your latest bank statement.

DECLARATION

I/We Authorise the following:

1. Rabbit International Pty Ltd to verify the details of the above account with my/our Financial Institution (Bank).

2. The Financial Instution to release inforamtion allowing Rabbit International Pty Ltd to verify the above account details.

3. That Rabbit International Pty Ltd debit my/our account in accordance with our Agreement.

SIGNATURES - fill in this form - leave the signature boxes blank. Print to your printer - sign in the signature boxes and fax or post to Rabbit.

If you have a joint bank account then please include BOTH signatures. You understand that a 99c processing fee is added per transaction on all direct debits. i.e. if Rabbit charges $10 it would show on your bank statement as $10.99 debit.

Signature 1: Date:

Signature 2: Date:

YOUR CONTACT DETAILS

Login Name: (if you are an existing Rabbit Customer - leave blank otherwise)

Contact Phone:

SEND IT TO US!

When you have completed, printed and then signed this form, fax to Rabbit on 03 9419 3699 - Then you can call straight away to have it applied to your account

or

post to PO Box 1701, COLLINGWOOD 3066. - allow two working days then call us to see if it has arrived - we will apply it to your account while we talk to you if it has.