"*" indicates required fields

Customer Details
Customer 1 Name*
Customer 2 Name (if applicable)
Customer 1 Date of Birth*
Customer 2 Date of Birth
Customer 1 Address*
Customer 2 Address
My/Our Nominated Account Details
Address of Financial Institution*
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:
On Date*