DIRECT DEBIT FORM | Syriac Church

Authority for recurring payment by Credit Card

Action

New Request

Alteration

Cancellation

Family Name

Given Name(s)

Mobile No.

Street address

Suburb

Post Code

Type of Card

Mastercard

Visa card

Card Number

Cardholder Name

Expiry Date

Description of goods/services

Payment Amount (AUD)

Frequency: Monthly

Date of first payment

Set payment end date

Cancellation effective date

Until end date

I hereby authorise the Merchant to debit my Card Account with the amount and at the intervals specified above for goods/services as described. This authority shall stand, in respect of the above specified Card and in respect of any Card issued to me in renewal or replacement thereof, until I notify the Merchant in writing of it’s cancellation.