Term Deposit Direct Debit Authorisation - Southern Cross Credit Union

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Customer Details

Customer 1 Name*

First Last

Customer 2 Name (if applicable)

First Last

Customer 1 Date of Birth*

Customer 2 Date of Birth

Customer 1 Address*

Street Address Address Line 2 Suburb / Town State Postcode

Customer 2 Address

Same as Customer 1 Address

Street Address Address Line 2 Suburb / Town State Postcode

My/Our Nominated Account Details

Name of Account*

BSB*

Account Number*

Name of Financial Institution*

Address of Financial Institution*

Street Address Suburb / Town State Postcode

Request and Authority to Debit
This Direct Debit request is subject to the Direct Debit Service Agreement found here.
I/We request and authorise Southern Cross Credit Union Ltd to debit, through the Bulk Electronic Clearing System, my/our nominated account with:

Amount*

On Date*

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CaseId

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