[E] Form of Request for Debiting Amounts to Accounts by the Direct Debit System

(Form PD-C)

To be returned to Membership Section, PSA/CPSU, GPO Box 3365, Sydney 2001 for processing.

Branch & Account Identification Number

Date _______/______/_________

Bank

Branch

I/We,

I/We understand and acknowledge that:

1. The Bank/Financial Institution may in its absolute discretion determine the order of priority of payment by it of any moneys pursuant to this Request or any authority or mandate.
2. The Bank/Financial Institution may in its absolute discretion at any time by notice in writing to me/us terminate this Request as to future debits.

The Schedule

NOTE: Direct debiting is not available on certain accounts. If in doubt, please refer to your bank/financial institution.

Title of Account:

Bank/State/Branch No. (Banks only) OR Financial Institution No.

Account No.

Date ______/______/_______

Home address:

State & Postcode:

Cancellation of Periodical Payment or Periodical Debit

In favour of Public Service Association of New South Wales.

Please cancel my existing Authority to you to debit my/our account and make payments to the abovementioned Company/Society etc for the amount of $ _________ in respect of Contract/Policy etc.


Signature

Date ______/_____/________

If paying by bank debit, please keep a copy of this form for your personal records. When you have read the obligations print out this form, complete it, then sign it.

The completed form must be posted to us as we need your signature.