Direct Debit form for Toniq Customers

TRADING NAME*

TRADING ADDRESS*

EMAIL FOR INVOICES & STATEMENTS*

NAME OF ACTING ACCEPTOR*

I confirm that I am an authority to submit and action the automated payments via direct debit for our business/company.

NAME OF ACCOUNT TO BE DEBITED*

NAME OF BANK*

BANK ACCOUNT (xx-xxxx-xxxxxxx-xxx)*

I/We authorise you until further notice in writing to debit my/our account with you with all amounts which TONIQ LTD the registered initiator of the Authorisation Code "3144066" may initiate by Direct Debit.

I/We acknowledge and accept that the Bank accepts this authority only upon the conditions listed here.