Direct Debit form for Toniq Customers

AUTHORITY TO ACCEPT DIRECT DEBITS
(Not to operate as an assignment or an agreement)

AUTHORISATION CODE: 3144066

 

 

    Company Trading Details

    TRADING NAME*

    TRADING ADDRESS*

    EMAIL FOR INVOICES & STATEMENTS*

    NAME OF ACTING ACCEPTOR*

     

    Banking Details

    NAME OF ACCOUNT TO BE DEBITED*

    NAME OF BANK*

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

     

    Information to appear on your statement

    PAYER PARTICULARS

    PAYER CODE

    PAYER REFERENCE