Direct Debit Contract

Request and Authority to debit the account named below to pay:

Please view the terms & conditions.


PersonalCompany




“You” request and authorise Staysafe (Aust) Pty Ltd (ID446688) to arrange, through its own financial institution, a debit to your
nominated account any amount Staysafe (Aust) Pty Ltd, has deemed payable by you.
This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution
you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

Schedule



MonthlyQuarterly
(Payments will continue until further notice.)

Choose your method of payment by filling out either:
Part A (Credit & Debit Cards) or Part B (Bank Account Details) below.

A) Credit/Direct Debit

MastercardVisa


B) Bank Account Details



Acknowledgment

By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to
the terms and conditions governing the debit arrangements between you and Staysafe (Aust) Pty Ltd as set out in this Request and
in your Direct Debit Request Service Agreement.

Signature




Date