Direct Debit Request Form

Direct Debit Request Form
Official request and authority to debit the account named below, to pay Netregistry Pty Ltd. Please
forward completed forms via fax to (02) 8079 0742 or post to: Netregistry Accounts, PO Box 270,
Broadway NSW 2007.
Customer Details
Account Reference: __________________________________________________________________________________________
Domain Name(s): ____________________________________________________________________________________________
Request and Authority to Debit
I request and authorise Netregistry Pty Ltd – User ID 248080 to arrange for any amount Netregistry Pty
Ltd may debit or charge to be debited through the Bulk Electronic Clearing System from an account held
at the financial institution identified below, subject to the terms and conditions of the Direct Debit
Request Service Agreement [as well as any further instructions provided below].
Full Name: ___________________________________________________________________________________________________
Company Name: _____________________________________________________________________________________________
ABN / ACN: __________________________________________________________________________________________________
Postal Address: ______________________________________________________________________________________________
Phone: ______________________________________________ Fax: ___________________________________________________
Financial Institution Details
Name of Financial Institution: _______________________________________________________________________________
Postal Address: ______________________________________________________________________________________________
Account Name: ______________________________________________________________________________________________
BSB Number: ___ ___ ___ ___ − ___ ___ ___ ___
Account Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
By signing this Direct Debit Request you hereby acknowledge having read and understood the terms and
conditions governing the debit arrangements between you and Netregistry Pty Ltd, as set out in Direct
Debit Request Service Agreement.
Signature: ______________________________________________________ Date: _____________________________________
Netregistry Pty Ltd. ABN 13 080 859 721 PO Box 270, Broadway NSW 2007 Australia
email [email protected] | fax 02 8079 0742 www.netregistry.com.au
Direct Debit Request Service Agreement
Definitions
Account: refers to the account held at your financial institution from which
we are authorised to arrange for funds to be debited.
Agreement: this Direct Debit Request Service Agreement between you and
us.
Business day: refers to a day other than a Saturday or a Sunday or a public
holiday listed throughout Australia.
Debit day: the day that payment by you to us is due.
Debit payment: a particular transaction where a debit is made.
Direct debit request: the Direct Debit Request between us and you
Us or we: refers to Netregistry Pty Ltd (“ Netregistry”), the Debit User you
have authorised by signing a direct debit request.
You: the customer who signed the direct debit request.
Your financial institution: the financial institution where you hold the
account that you have authorised us to arrange to debit.
1.
Debiting your
account
2. Change by us
1.1
By signing a direct debit request, you have authorised us to arrange
for funds to be debited from your account. You should refer to the
direct debit request and this agreement for terms of the
arrangement between you and us.
1.2
We will only arrange for funds to be debited from your account as
authorised in the direct debit request
OR
We will only arrange for funds to be debited from your account if we
have sent (to the address nominated by you in the direct debit
request) a billing advice, specifying the amount payable by you to us
and when it is due.
1.3
If the debit day falls on a day that is not a business day, we may
direct your financial institution to debit your account on the
following business day.
1.4
If you are unsure about which day your account has or will be
debited, you should ask your financial institution.
2.1
We may vary any details of this agreement or a direct debit request
at any time, by providing you at with at least fourteen (14) days’
written notice.
Netregistry Pty Ltd. ABN 13 080 859 721 PO Box 270, Broadway NSW 2007 Australia
email [email protected] | fax 02 8079 0742 www.netregistry.com.au
Direct Debit Request Service Agreement
3. Changes by you
4. Your obligations
3.1
Subject to 3.2 and 3.3, you may change the arrangements under a
direct debit request by contacting us directly on
(02) 9934 0501
3.2
If you wish to stop or defer a debit payment you must notify us (in
writing) at least 5 days before the next debit day. This notice should
be given to us in the first instance.
3.3
You may also cancel your authority for us to debit your account at
any time by giving us 5 days notice (in writing) before the next debit
day. This notice should be given to us in the first instance.
4.1
It is your responsibility to ensure that there are sufficient clear funds
available in your account to allow a debit payment to be made, in
accordance with the direct debit request.
4.2
If there are insufficient clear funds in your account to meet a debit
payment:
(a) you may be charged a fee and/or interest by your financial
institution;
(b) you may also incur fees or charges imposed or incurred by us;
and
(c) you must arrange for the debit payment to be made by another
method or arrange for sufficient clear funds to be in your account by
an agreed time so that we can process the debit payment.
5. Dispute
4.3
You should check your account statement to verify that the amounts
debited from your account are correct.
4.4
If Netregistry is liable to pay goods and services tax ("GST") on a
supply, made in connection with this agreement, then you agree to
pay Netregistry on demand an amount equal to the consideration
payable for the supply multiplied by the prevailing GST rate.
5.1
If you believe that there has been an error in debiting your account,
you should notify us directly on (02) 9934 0501and confirm via a
notice (in writing) with us as soon as possible so that we can resolve
your query in a timely fashion.
5.2
If we conclude, as a result of our investigations, that your account
has been incorrectly debited we will respond to your query by
arranging for your financial institution to adjust your account
(including interest and charges) accordingly. We will also notify you
(in writing) of the amount by which your account has been adjusted.
5.3
If we conclude, as a result of our investigations, that your account
Netregistry Pty Ltd. ABN 13 080 859 721 PO Box 270, Broadway NSW 2007 Australia
email [email protected] | fax 02 8079 0742 www.netregistry.com.au
Direct Debit Request Service Agreement
has not been incorrectly debited we will respond to your query by
providing you with reasons and any evidence for this finding.
6. Accounts
5.4
Any queries you may have about an error made in debiting your
account should be directed to us in the first instance so that we can
attempt to resolve the matter between you and us. If we cannot
resolve the matter you can still refer it to your financial institution,
which will obtain details from you of the disputed transaction and
may lodge a claim on your behalf.
6.1
You should check:
(a) with your financial institution whether direct debiting is available
from your account, as direct debiting is not available on all accounts
offered by financial institutions.
(b) your account details which you have provided to us are correct
by checking them against a recent account statement; and
(c) with your financial institution before completing the direct debit
request, if you have any queries about how to complete the direct
debit request.
7. Confidentiality
7.1
We will keep any information (including your account details) in your
direct debit request confidential. We will make reasonable efforts to
keep any such information that we have about you secure and to
ensure that any of our employees or agents who have access to
information about you do not make any unauthorised use,
modification, reproduction or disclosure of that information.
7.2
We will only disclose information that we have about you:
(a) to the extent specifically required by law; or
(b) for the purposes of this agreement (including disclosing
information in connection with any query or claim).
8. Notice
8.1
If you wish to notify us in writing about anything relating to this
agreement, please write to Netregistry Pty Ltd, Finance &
Administration, PO Box 270, Broadway, NSW, 2007.
8.2
We will notify you by sending a notice in the ordinary post to the
address you have given us in the direct debit request.
8.3
Any notice will be deemed to have been received within two business
days after it is posted.
Netregistry Pty Ltd. ABN 13 080 859 721 PO Box 270, Broadway NSW 2007 Australia
email [email protected] | fax 02 8079 0742 www.netregistry.com.au