107 Great South Road, Papakura 2110
PO Box 72243, Papakura 2244
Ph: 09 295 0515 Fax: 09 296 2632
Tax Invoice GST Reg No: 67 868 439
DIRECT DEBIT APPLICATION
Water Account No.
Customer Name:
Property Address:
Postal Address:
(if different from above)
Phone Number(s)
Home/Work:
Mobile:
Bank Account Details:
(from which your payments are to be made from)
Name of Account Holder:
Please supply evidence of your bank account number to ensure your account is loaded correctly.
Your application may not be processed by Veolia without this information.
PLEASE NOTE: Veolia accepts no responsibility for incorrect bank details provided by the customer.
-
-
-
BANK
BRANCH No.
ACCOUNT No.
SUFFIX
To The Bank Manager Of:
Name of Bank:
AUTHORISATION CODE
Branch
Town/City
I/We authorise you, until further notice in writing, to debit my/our account with all amounts which Veolia, the registered
initiator of the above Authorisation code, may initiate by Direct Debit.
I/We acknowledge and accept that the bank accepts this authority only upon the condition listed on the reverse of this
form.
Your signature(s) must appear below:
1.
Date: / /20
2.
Date: / /20
0
3
1
2
6
4
6
Information to appear on Veolia’s bank statement:
This Direct Debit will take effect on future accounts only.
Invoices issued prior to completing this application need to be paid manually.
CUSTOMER NAME
VEOLIA ACCOUNT NUMBER
APPROVED
1264
FOR BANK USE ONLY
Original - Retain at Branch
BANK STAMP
09
06
Date Received
Recorded By
Checked By
TEM-2567-2
Issue Date 05/12/2018
Review Period: 3 Yearly
Uncontrolled when printed
Page 1 of 2
107 Great South Road, Papakura 2110
PO Box 72243, Papakura 2244
Ph: 09 295 0515 Fax: 09 296 2632
Tax Invoice GST Reg No: 67 868 439
CONDITIONS OF THIS AUTHORITY
1. The Initiator:
a. Has agreed to give written advance notice of the net amount of each direct debit and the due date of debiting at least 10
calendar days before (but not more than 2 calendar months) the date the direct debit will be initiated.
The advance notice will include the following message:-
Unless advice to the contrary is received from you be (*date), the amount of $__________ will be directly debited to your bank
account on (initiating date).
*This date will be at least two days prior to the due date to allow for amendment of direct debits.
b. May, upon the relationship which gave rise to this Authority being terminated, give notice to the bank that no further Direct
Debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future
payments by notice in writing to me/us.
2. The Customer may:
a. At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the
initiator.
b. Stop payment of any direct debit to be initiated under this Authority by the initiator by giving written notice to the bank prior
to the direct debit being paid by the Bank.
c. Where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has
been made without notice being given in terms of 1(a) above, request the Bank to reverse or alter any such Direct Debit
initiated by the Initiator by debiting the amount of the reversal or alteration of the Direct Debit back to the Initiator through
the Initiator’s Bank, PROVIDED such request is made not more than 120 days from the date when the Direct Debit was
debited to my/our account.
3. The Customer acknowledges that:
a. This Authority will remain in full force and effect in respect of all direct debits made from me/our account in good faith
notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received
by the bank.
b. In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to
my/our account.
c. Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank
except in so far as the direct debit has not been paid in accordance with this Authority. Any other disputes lie between me/us
and the Initiator.
d. Where the Bank has used reasonable care and skill in acting in accordance with this Authority, the Bank accepts no
responsibility or liability in respect of:-
● the accuracy of information about Direct Debits on Bank statements
● any variations between notices given by the initiator and the amounts of Direct Debits.
e. The Bank is not responsible for, or under any liability in respect of the Initiator's failure to give written advance notice
correctly nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the
dispute lies between me/us and the initiator.
4. The Bank may:
a. In its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any
other authority, cheque or draft properly executed by me/us and given to or drawn on the Bank.
b. At any time terminate this Authority as to future payments by notice in writing to me/us.
c. Charge its current fees for this service in force from time-to-time.
TEM-2567-2
Issue Date 05/12/2018
Review Period: 3 Yearly
Uncontrolled when printed
Page 2 of 2
