paysolutions pty ltd
 PAY SOLUTIONS PTY LTD
ABN 52 098 637 846
Ph: 1300 131 425
Fax: 1300 131 682
PO BOX 488
EMU PLAINS NSW 2750

Centre/Business Name:

Pay Solutions Client No: (PAY SOLUTIONS USE ONLY)

NEW PAY SOLUTIONS CUSTOMER EXISTING PAY SOLUTIONS CUSTOMER

Customer Details

Customer/Contact Name:
Given Name/s
Surname
Address:


Street Number and Name


Suburb


Postcode

Telephone:

Home Phone

Mobile Phone

Work Phone
Email:

Terms and Conditions

I/We hereby authorise Pay Solutions Pty Ltd (Debit User) ID 203206 to debit the account listed below on behalf of the Business/Centre named above

First Debit Date / /
First Debit $
Regular Debit $
Plus (tick whichever is applicable)
Admin Fee
$ plus/or %
Set Up Fee $ (once off)
Until Further Notice OR
Payments
Weekly Fortnightly
Monthly 4 weekly

DIRECT DEBIT AUTHORITY FROM BANK ACCOUNT

Financial Institution Name:
Branch Address:
Name of Account Holder/s:
  Given Name/s Surname
BSB: (6 digits)  
Account Number:  

CREDIT CARD

Please charge my Visa Mastercard Amex Diners
Name on card:
Credit Card Number:
Exipy Date: / Signature of Cardholder: _______________________________________________________

Direct Debit Request Authorisation

I/We have read and agree to the "Service Agreement"
Account Holder/s Signature/s: __________________________________________ Date: ____ / ____ / ____
 


__________________________________________


Date: ____ / ____ / ____

 

 

 

Service Agreement

 

  1. Pay Solutions Pty Ltd (the “Debit User”) will debit the Account nominated in the Schedule of this Direct Debit
    Request as specified.

  2. Any alteration to the debiting schedule will be considered subject to the terms and conditions of any agreement
    between you and the business named overleaf for whom Pay Solutions Pty Ltd acts on behalf of.

  3. The Debit User will give not less than 14 days written notice to the customer should it propose to vary the
    arrangements of this Direct Debit Request.

  4. In compliance with the Industry’s Direct Debit Claims Process, the Debit User will assist customer(s) disputing any
    payment amount drawn on the nominated BSB/Account in The Schedule of this Direct Debit Request. The Debit
    User will endeavor to resolve this matter within the Industry agreed timeframes. Any disputed debit items resolved
    in favour of Pay Solutions will incur and administration fee.

  5. The Debit User advises that some Financial Institution accounts do not facilitate direct debits and as such the
    customer(s) must check with their Financial Institution to ensure the account nominated in The Schedule of this
    Direct Debit Request enables direct debiting.

  6. It is the customer(s) responsibility to ensure at all times there is sufficient cleared funds available, at the due date of the debit drawing, to enable payment from the BSB/Account as nominated in The Schedule of this Direct Debit
    Request. Direct Debits normally occur overnight, however transactions can take up to two (2) working days
    depending on your financial institution.

  7. The Debit User advises the debit drawing will be made on the agreed due date as nominated in The Schedule of this
    Direct Debit Request. When the due date is a closed business day the Debit User will initiate the debit drawing on
    the next open business date.

  8. Where an unpaid debit item is returned by a Financial Institution the customer(s) will be responsible for the debit
    plus any return fee’s and administrative costs incurred by Pay Solutions Pty Ltd.

  9. Pay Solutions (Debit User) will not stop or cancel a direct debit without the written authority / request of the
    business named overleaf for whom Pay Solutions Pty Ltd acts on behalf of.

  10. The Debit User agrees to keep confidential all customer(s) records and account details contained in The Schedule of
    this Direct Debit Request unless authorised to release such information pursuant to a debit item dispute or similar
    event where the customer(s) has provided prior consent to do so.