Direct Debit Authority Form Sample Contracts

Complete the DD authority form, place in an envelope and address to:
Direct Debit Authority Form • March 18th, 2011

Direct Debit Authority Form Authority to Accept Direct Debits(not toName of account holder: operate as anassignment orBank Branch Number Account Number Suffix agreement) (May be only 2 digits)To: The Manager Authorisation Code1208311Name of Bank: Postal Address: City: I/We authorise you until further notice in writing to debit my/our account with you all amounts which: PINNACLE LIFE (hereafter referred to as the Initiator) the registered Initiator of the above authorisation code may initiate by Direct Debit. I/We acknowledge and accept the bank accepts this authority only upon the conditions listed below. Payer Particulars Payer Code Payer Reference Authorised signature:_ Date: / / For bank use only Approved083102/07 Date Received: Recorded By: Checked By Bank Stamp

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