Membership Application
|
|
- Ada Allen
- 8 years ago
- Views:
Transcription
1 Membership Application YMCA OF CENTRAL AUSTRALIA INC. PO Box 2458, Sadadeen Rd, Alice Springs NT 0871 Telephone: (08) Facsimile: (08) Personal Details Title: Surname: Preferred Name: Date of Birth: / / Sex: M / F (Please circle) Home Address: P/Code: Phone (h) (w) (m) Previous Member: Yes / No Emergency Contact Details Name: Relationship: Phone (h) (w) (m) I,, hereby agree to abide by all rules and regulations of the YMCA of Central Australia and agree to pay the applicable membership fees. 0 I understand my membership is non-transferable and fees are subject to change. 0 I understand that my membership may be suspended for a maximum of 8 weeks per annum. A $10 fee is applicable per each suspension. Memberships are refundable only within 7 days of purchase, minus an administration fee or will be considered on presentation of an appropriate medical certificate. ADULT DECLARATION I hereby agree that the YMCA and its officers, leaders, staff and agents shall be released from and shall not incur any responsibility or liability for any accident or injury sustained by me or for any damage to or loss of my property. I further authorise you to obtain at my cost medical/ambulance assistance in the case of an accident or emergency involving me. Signature: Date: / / Office Use Only: Staff Initials: M/Ship Type: M/Ship No.: Membership added to tally: Members added to address book:
2 YMCA OF CENTRAL AUSTRALIA INC. PAR-Q FORM The PAR-Q (Physical Activity Readiness - Questionnaire) form is designed to assess whether you need a medical clearance before you commence an exercise program or increase your current level of physical activity. Please read each question carefully and answer them to the best of your knowledge. 1. Has your doctor ever said you have heart trouble? YES NO 2. Do you frequently suffer pains in your heart or chest? YES NO 3. Do you often feel faint or have spells of severe dizziness? YES NO 4. Has your doctor ever said your blood pressure is too high YES NO (over 145/90 mmhg)? 5. Has your doctor ever said that you have a severe bone, joint or YES NO muscle problem such as arthritis that has been aggravated by exercise or might be made worse be exercise? 6. Are you pregnant? YES NO 7. Are you over the age of 50? YES NO 8. Is there any other physical reason not mentioned here which YES NO may cause serious harm by exercising? If you answered YES to any of the above questions you are required under the guidelines of YMCA of Central Australia Inc and Active Australia, to consult a doctor for a medical clearance prior to participating in our Health Club Active Australia also recommends that the following people should consult a doctor to obtain a medical clearance: People with chronic health problems, such as heart disease, diabetes, or obesity, or who are at high risk for these problems and beginning a new program of physical activity. Older people returning to competitive or strenuous physical activity, whether or not they have a history of or risk factors for cardiovascular disease. The YMCA acknowledges and respects the privacy of individuals. The information that is being collected on this document is for the purposes of providing you with an appropriate exercise plan specific for your needs. The personal and health information collected is required to determine preexisting conditions, which may influence your ability to participate in a program. By completing this form, the YMCA accepts that you, your parents/guardians (if a person under the age of 18) have consented for this information to be collected. The intended recipients of this information are the YMCA, and its authorised staff. You have the right to access and alter personal or health information concerning in accordance with the Commonwealth Privacy Act (Amended 2001) and YMCA Privacy Policy. As part of your membership/ enrolment with the YMCA, you will receive information from time to time regarding our programs and services. The YMCA may also provide promotional material from our strategic partners, or any other third party, if you do not wish to receives this information please tick the " OPT OUT" box below and return this to the YMCA. Your name will be removed from the mailing list within a reasonable period of time. OPT OUT....../.../ Signed Date Witness / Instructor
3 ABN: Direct Debit Request (DDR) Authorisation Form Updated in Links Change added to tally added/removed CUSTOMER DETAILS Cust: Ref #: Given Name: Surname: (Or Company Name) Address: Street Name and Number City State P/code Telephone: Mobile Work Phone Home Phone PAYMENT ARRANGEMENT For the total amount billed for the specified period for this and any other subsequent agreements or amendments including associated fee/charges as detailed. Single Payment: Recurring Payment: / / debit the amount of: $ debit the amount of: $,. Payment Frequency: Weekly Fortnightly Monthly ( Payment Term: (Select one only) Continue until further notice Until I have paid $. OR regular payments Transaction Fee Direct Debit: $0.65 Credit Card: Visa/Mastercard 1.50% (min $0.65) BANK ACCOUNT AUTHORISATION Direct Debit is not available on the full range of accounts if in doubt please refer to your financial institution Financial Institution Branch BSB Number Account Number 9 Digits MAX Account Holder Name I / We authorise LinksPay Pty Ltd ABN , User ID , to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System (BECS) in accordance to the Payment Arrangements stated above and this Direct Debit request and as per the DDR Service Agreement provided. CREDIT CARD AUTHORISATION Please charge my periodical payments to my (please tick one): VISA MasterCard Amex Card Number Name on Card (exactly how it appears on card) Expiry Date / M M Y Y This Authorisation is to remain in force in accordance with the Terms and Conditions on this Direct Debit Request, the provided DDR Service Agreement, and I/we have read and understand the same. X AUTHORISING SIGNATURE Date / / Ver: 19
4 ABN: DDR Service Agreement This Agreement is designed to explain what your obligations are when undertaking a Direct Debit arrangement with LinksPay and the Business. It also details what our obligations are to you as your Direct Debit Provider. We recommend you keep this agreement in a safe place for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR form I/We hereby authorize LinksPay Pty Ltd (ABN: ) Direct Debit User ID to make periodic debits on behalf of the Business as indicated on the front of this Direct Debit Request (herein referred to as the Business) I/We acknowledge that LinksPay is acting as a Direct Debit Agent for the Business and that LinksPay does not provide any goods or services and has no express or implied liability in regards to the goods and services provided by the Business or the terms and conditions of any agreement with the Business. I/We acknowledge that LinksPay and the Business will keep any information (including account details) contained in the Direct Debit Request confidential. LinksPay and the Business will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. We will only disclose information that we have about you: (a) to the extent specifically required by law; or (b) for the purposes of this agreement (including disclosing information in connection with any query or claim). I/We acknowledge that the debit amount will be debited from my/our account according to the Direct Debit Request, this Agreement and the terms and conditions of the agreement with the Business. I/We acknowledge that bank account details have been verified against a recent bank statement to ensure accuracy of the details provided. If uncertain you should contact your financial institution. I/We acknowledge that is my/our responsibility to ensure that there is sufficient cleared funds in the nominated account by the due date to enable the direct debit to be honoured on the debit date. Direct debits normally occur overnight; however transactions can take up to three (3) business days depending on your financial institution. I/We acknowledge and agree that sufficient funds will remain in the nominated account until the direct debit amount has been debited from the account and that if there are insufficient funds available, I/We agree that LinksPay will not be held responsible for any fees and charges that may be charged by your financial institution. I/We Acknowledge that there may be a delay in processing if: 1) There is a public or bank holiday on the day, or any day after the debit date 2) A payment request is received by LinksPay on a day that is not a Banking Business Day 3) A Payment request is received after normal operational hours, being 4pm Monday to Friday. Any payments that fall due on any of the above will be processed on the next business day. I/We authorise the Business to vary the amount of the payments from time to time as provided for within the Business agreement. I/We authorise LinksPay to vary the amount of the payments upon instructions from the Business. I/We do not require LinksPay to notify me/us of such variations to the debit amount. I/We acknowledge that the total amount billed will be for the specified period for this and/or subsequent agreements and/or amendments. I/We acknowledge that the Business is to provide 14 days notice if proposing to vary the terms of the debit arrangements. I/We acknowledge that variations to the debit arrangement will be directed to the Business. I/We acknowledge that any request to stop or cancel the debit arrangement will be directed to the Business. I/We acknowledge that any disputed debit payments will be directed to the Business. If no resolution is forthcoming you are advised to contact your financial institution. I/We acknowledge that if a debit is returned by my/our financial institution as unpaid, I/We will be responsible for any fees and charges for each unsuccessful debit in addition to any financial institution charges and collection fees, including and not limited to any solicitor fees and collection agent fees appointed by LinksPay. I/We authorise LinksPay to attempt to re-process any unsuccessful payments as advised by the Business. I/We acknowledge that if specified by the Business, a setup, variation, dishonour, SMS or processing fees may apply as instructed by the Business. I/We authorise: 1) The Debit User to verify details of my/our account with my/our financial institution 2) The Financial Institution to release information allowing the Debit User to verify my/our account details. LinksPay Pty Ltd ABN: P.O Box 6290, Upper Mt Gravatt, Queensland 4122 Ph: Fax:
5 1. INTRODUCTION This document outlines the rights and responsibilities you have with regard to the ability of YMCA OF CENTRAL AUSTRALIA INC. to directly debit your nominated bank account for any instalments or fees due by you under the terms and conditions of the Contract and DDR Service Agreement, the terms of which are stated below. Should you have queries regarding your Contract or this DDR fo rm you should in the first instance contact YMCA OF CENTRAL AUSTRALIA INC. on PHONE NO YMCA OF CENTRAL AUSTRALIA INC. Contract & Client Service Agreement 2. PAYMENTS YMCA OF CENTRAL AUSTRALIA INC. will debit your nominated account for the amount and at the frequency of payments as agreed between us on the YMCA OF CENTRAL AUSTRALIA INC. DDR Contract signed and accepted by you. If the nominated day of your debit falls on a public holiday or weekend, YMCA OF CENTRAL AUSTRALIA INC. will debit your account on the next business day. It is your responsibility to have clear funds in your account on the due date of the direct debit. The customer agrees to pay the instal ment amount at the agreed payment frequency until this Contract is terminated in accordance with clause 4 below. Should there be any arrears in payments the Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to debit the outstanding balance in order to bring the account up to date. The contract of membership can be voided within 7 days of joining and total monies refunded without further obligation. All terms and conditions of membership are binding after 7 days. 3. SUSPENSION FOR MOST MEMBERSHIPS Suspension of payments is possible under the terms of your Contract. Payments may be suspended for a minimum of two weeks and a maximum of 8 weeks at a time. Suspension requests must be made 3 days prior to the next direct debit by completing a Customer Request form or ed directly to YMCA OF CENTRAL AUSTRALIA INC. at reception.ca@ymca.org.au. A charge of $10 suspension applies. All medical suspensions are free upon presentation of a valid doctor s medical certificate. 4. CANCELLATION The Customer may cancel this Contract by completing a Customer Request Form if all the fees due up to the date of termination are paid in full. A period of 3 days notice must be given before the due date of the next debit to terminate that payment; or the next full membership payment will be deducted. Please note, memberships are ongoing. Your account will continue to be debited until an amendment form has been completed with notice of cancellation. Monthly fees are non refundable. 5. YOUR OTHER RESPONSIBILITIES In addition to those already mentioned, you are responsible for ensuring that your nominated account is able to accept direct debits. If it is not, it is your responsibility to provide YMCA OF CENTRAL AUSTRALIA INC. with a new account number. You are responsible to notify YMCA OF CENTRAL AUSTRALIA INC. of any changes to your debit details or contact details by completing a Customer Request form or contact YMCA OF CENTRAL AUSTRALIA INC. at reception.ca@ymca.org.au. The member is responsible to forward all correspondence on to the bank or debit account holder. 6. DISHONORED PAYMENTS Should your payment be dishonoured, YMCA OF CENTRAL AUSTRALIA INC. will debit you an additional $15 with your next payment and, if we have not received instructions to the contrary from you, debit both the current due payment and the now overdue payment(s) on the same day. In the event of payments being dishonoured on two consecutive occasions YMCA OF CENTRAL AUSTRALIA INC. reserves the right to terminate your Contract. YMCA OF CENTRAL AUSTRALIA INC. may charge any other fees or costs involved with debit collection. 7. INCREASE IN FEES AND CHANGE OF TERMS YMCA OF CENTRAL AUSTRALIA INC. may at any time upon sending written notice to the customer s last known address and giving 30 days notice, increase the instalment amount. In the event that the initial terms are to change, they can only do so in accordance with your contract a nd we must give you at least 14 days notice of the changes including if applicable new frequency and next debit date. If you have any questions on proposed changes, please contact your chosen YMCA Branch. 8. DISPUTES All disputes regarding a direct debit payment should be referred to YMCA Membership Response Service by phone , reception.ca@ymca.org.au or in writing. 9. AVAILABILITY OF SERVICES YMCA OF CENTRAL AUSTRALIA INC. reserves the right to alter the operational hours or provision of available services at any time without notice. 10. ENTITLEMENT The Customer acknowledges that provision of services provided by the Branch may change and for the purposes of this Contract is based on entitlement to use and not on actual use. The customer agrees to be bound by the rules and conditions of the Branch. The Branch and /or YMCA OF CENTRAL AUSTRALIA INC. may terminate entitlement of the use of the Branch if any Customer fails to comply with the rules of conduct of the Branch or fails to make payment of any fee on the due date. 11. PROVISION OF SERVICE Change of location or ownership or the name of the Branch does not absolve the Customer of responsibilities under the terms and conditions of this Contract. 12. CREDIT/DEBT REPORTING AGENCIES THE Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to notify any debt collection/credit-reporting agency upon default by the Customer in regard to any obligation under this Contract. Should this occur then at YMCA OF CENTRAL AUSTRALIA INC. sole discretion, it may terminate the contract at which time the full outstanding balance for the remainder of the minimum term or payments including any current arrears shall be immediately due in full. In addition YMCA OF CENTRAL AUSTRAL IA INC. shall add $30 to the outstanding debt as its fee for dealing with the defaulting member. The Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to add any further amount to the outstanding debt that might be reasonably incurred by YMCA OF CENTRAL AUSTRALIA INC. in collecting the outstanding debt. This further amount shall include the fees of the agency to which the account is referred, which are based on the total amount collected by them. 13. ENTIRE AGREEMENT This Contract and DDR Service Agreement constitute the entire agreement, understanding and arrangement (express and impli ed) between the Customer, the Branch and YMCA OF CENTRAL AUSTRALIA INC. relating to the subject matter of this Contract and supersede and cancels any previous agreement, understanding and arrangement relating thereto whether written or oral. 14. PRIVACY The YMCA OF CENTRAL AUSTRALIA INC. acknowledges and respects the privacy of individuals. The information that is being collected on this document is for the purpose of servicing your membership subscription and financial institution payments. This information provides accurate personal information in order to carry out the financial transaction requested. The intend ed recipients of this information are the YMCA, its authorised staff and contracted service providers, such as financial institutions and Government agencies covered by law. You have the right to access and alter personal information, protecting yourself in accordance with the Commonwealth Privacy Act (Amended 2001), and the YMCA Privacy Policy. If you do n ot wish to have your information used or disclosed for this purpose, the YMCA OF CENTRAL AUSTRALIA INC. will be unable to process your financial transactions. Your account records and details will not be disclosed to any outside person or entity accept in accordance with the rules laid down in the Contract and where such information is required in connection with any claim for an alleged incorrect or wrongful debit. As part of your membership with YMCA OF CENTRAL AUSTRALIA INC., you will receive information from time to time regarding our programs and services. The YMCA may also provide promotional material from our strategic partners, or any other third party, if you do not wish to receive this information please tick the OPT OUT box on the front of the Direct Debit Contract and return to the YMCA. Your name will be removed from the mailing list within a reasonable period of time. 15. LIABILITY To the extent permitted by law, the Branch and YMCA OF CENTRAL AUSTRALIA INC. shall not be liable or responsible to the Customer for any direct, indirect or consequential injury, loss or damage to the Customer whatsoever and howsoever arising. Should this contract relate to payments for the entitlement to use fitness, health or aquatic facility, the Customer acknowledges that with any physical activity, as is likely to be carried out by the Customer at the Branch, there is a risk of both minor and major accidents, injury and death. Understanding and acknowledging this risk, the Customer agrees to use the Branch at their own risk.
ABN: 256 523 26121 PH: 07 5592 5800 FAX: 07 5592 5855 DIRECT DEBIT REQUEST - NEW CUSTOMER
DIRECT DEBIT REQUEST - NEW CUSTOMER Business: Kidz Kingdom Childcare Centre ABN/ACN: 46092385343 Customer Reference: *Surname: *First Name: Mobile Phone: *Email: *Address: * indicates a mandatory field.
More informationCORPORATE VOLUNTARY DIRECT DEBIT APPLICATION
CORPORATE VOLUNTARY DIRECT DEBIT APPLICATION 1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of
More informationHow To Pay Your Water Bill With Direct Debit
Direct Debit Making it easier to pay your bill The simple way to pay your account We understand that sometimes it feels like there are not enough hours in the day, especially when it comes to finding time
More informationApplication Form ABN: 63 135 196 397. PO Box 6290 Upper Mt Gravatt, Queensland 4122 Ph: 07 3040 4320 Fax: 07 3343 8590. Email: admin@integrapay.com.
Application Form ABN: 63 135 196 397 PO Box 6290 Upper Mt Gravatt, Queensland 4122 Ph: 07 3040 4320 Fax: 07 3343 8590 Email: admin@integrapay.com.au Australian Financial Services Licence No. 418105 Business
More informationPLEASE DO NOT STAPLE.
YOUR APPLICATION 1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave
More informationJoin GMHBA Transfer from an existing GMHBA membership Change my GMHBA cover
Application form September 2012 1. I wish to (please tick) Join GMHBA Transfer from an existing GMHBA membership Change my GMHBA cover GMHBA member number (existing members only) Cover or change of cover
More informationService Delivery Direct Debit Request (DDR)
Section 1: Business Details Name, Person 1 Name, Person 2 Position, Person 1 Position, Person 1 Business Name Trading Name ABN Amovita Client ID Street Address Postal Address Office Phone Mobile Phone
More informationApplication Form ABN: 63 135 196 397. PO Box 6290 Upper Mt Gravatt, Queensland 4122 Ph: 07 3040 4320 Fax: 07 3343 8590. Email: admin@integrapay.com.
Application Form ABN: 63 135 196 397 PO Box 6290 Upper Mt Gravatt, Queensland 4122 Ph: 07 3040 4320 Fax: 07 3343 8590 Email: admin@integrapay.com.au Australian Financial Services Licence No. 418105 Business
More informationIntelliTrac GPS Fleet Management
IntelliTrac GPS Fleet Management SBT (Small Business GPS Tracker) 24 Month Contract Agreement 11 Scholar Drive Bundoora Vic 3083 Phone (03) 9467 6188 Fax (03) 9466 7188 ABN 31-238-398-354 Applicant Company
More informationfirst choice home insurance application first choice home
first choice home insurance application first choice home CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please read the following information before you complete the application. Keep this
More informationMis-Sold Payment Protection Insurance (PPI) Claims Pack
Mis-Sold Payment Protection Insurance (PPI) Claims Pack Debt Clear Solutions is delighted to enclose an information and application pack that will enable us to reclaim any mis-sold Payment Protection Insurance
More informationBT Classic Investment Funds Additional and Regular Investments Request
BT Classic Investment Funds Additional and Regular Investments Request BT Customer Relations 132 135 (8.00am 6.30pm Mon-Fri, Sydney time) The Responsible Entities for the Funds offered through BT Classic
More informationA P P L I C A T I O N F O R T E N A N C Y
A P P L I C A T I O N F O R T E N A N C Y Property Applying For IMPORTANT IF YOU ARE SERIOUS ABOUT HAVING YOUR APPLICATION APPROVED, YOU MUST FILL IN ALL THE FIELDS REQUIRED. WHERE FIELDS DO NOT APPLY
More informationinvestment portfolio service
investment portfolio service overview Cavendish is a specialist administrator of Self Managed Superannuation Funds (SMSFs). Our overriding business objective is to provide our clients the Trustees of the
More informationX VIC X NSW/ACT X QLD X SA X NT X WA X TAS
your OVERSEAS VISITORS application 1. Please complete this form using black ink and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a cross. Start at the left of each answer
More informationmotor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle
motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please read the following
More informationDirect Debit Request Service Agreement
National Australia Bank Limited ABN 12 004 044 937 Direct Debit Request Service Agreement Definitions 1. Debiting your account 2. Changes by us 3. Changes by you 4. Your obligations 543-339 (2/01)_Intranet
More informationMySmile Dental Plan Request
MySmile Dental Plan Request By completing this form I wish to commence a MySmile Dental Plan for my estimated Plan and understand and agree to the terms and conditions of the MySmile Dental Plan and Direct
More informationSmart Term Insurance
Smart Term Insurance Combined Product Disclosure Statement and Financial Services Guide Product Disclosure Statement About Smart Term Insurance HCF Smart Term Insurance is a term life insurance product
More informationBUSINESS CARD APPLICATION FORM COMPANY SECTION BUSINESS CARD APPLICATION FORM EMPLOYEE SECTION. Company Name (legal): Company Name:
BUSINESS CARD APPLICATION FORM EMPLOYEE SECTION Company Name: Employee Name: Title (Mr, Ms, Mrs): ID/PP/DP# Country/Date of Birth: Nationality: Sex: Male Female Name on Card: Mailing Address: Telephone
More informationBusiness Banking Online application
Business Banking Online application This application will register you to Business Banking Online and allow you to: Access accounts held by ONE company or business entity Process Credit Direct Entry file
More informationPay-by-the-month Insurance
Improve your business cash flow Pay-by-the-month Insurance Application form The insurer is AAI Limited ABN 48 005 297 807 trading as GIO. This product is distributed by Resilium Pty Ltd ABN 40 098 080
More informationBusiness Telephone Banking Administration form
Westpac Banking Corporation ABN 33 007 457 141 AFSL 233714 Business Telephone Banking Administration form Our privacy policy is available at westpac.com.au or by calling 132 032 and covers how we handle
More informationApplication Form July 2014
Application Form July 2014 1. I wish to (please tick) Join GMHBA Transfer from an existing GMHBA membership Change my cover GMHBA member number (existing members only) Cover or change of cover to commence
More informationLIV TRUST ACCOUNTING ONLINE SOFTWARE
LIV TRUST ACCOUNTING ONLINE SOFTWARE APPLICATION FORM A simple cost-effective solution to enhance efficient practice management. Please complete the following 3 sections and return the form. The set-up
More informationExpiry Date. If you have selected Cheque please nominate payee
TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process
More informationClaim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return
Savannah Insurance Agency Pty Ltd ABN 84 130 364 313 Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details
More informationI loved reading the terms & conditions! said no one, ever. term deposit terms + conditions
I loved reading the terms & conditions! said no one, ever term deposit terms + conditions index. Part a - general terms and conditions. 2 1 Purpose of this booklet. 2 2 Meaning of words used. 2 3 Opening
More informationRegistration Form for DCB Business Internet Banking
Registration Form for DCB Business Internet Banking Branch : Account Name: Corporate ID (Customer ID) : 1. Account Holder's Declaration, Request and We: (a) Maintain an account with the DCB Bank Limited
More informationNAB 100% Investment Loan. Client Application
NAB 100% Investment Loan Client Application Risk Disclosure Statement There are risks associated with using a NAB 100% Investment Loan Facility to borrow on the security of investments. You should be aware
More informationAccident And/Or Sickness Claim Form
Accident And/Or Sickness Claim Form Please forward this completed form to: Claims Department JUA Underwriting Agency Pty Ltd Locked Bag 11 ROYAL EXCHANGE POST OFFICE NSW 1225 Policy underwritten by certain
More informationANZ Commercial Card TERMS AND CONDITIONS 11.2015. ANZ Corporate Card ANZ Visa Purchasing Card ANZ Business One
ANZ Commercial Card TERMS AND CONDITIONS 11.2015 ANZ Corporate Card ANZ Visa Purchasing Card ANZ Business One Containing Terms and Conditions for: Facility Terms and Conditions Electronic Banking Conditions
More informationONLINE CREDIT ACCOUNT APPLICATION FORM
ONLINE CREDIT ACCOUNT APPLICATION FORM Woolworths Limited respects your privacy. We will only use your personal information to manage your Account. If this information is not provided, we might not be
More informationAPPOINTMENT OF DEBT COLLECTOR. Pursuant to Debt Collectors (Field Agents and Collection Agents) Act 2014
APPOINTMENT OF DEBT COLLECTOR Pursuant to Debt Collectors (Field Agents and Collection Agents) Act 2014 BETWEEN: SHIRAN (QLD) PTY LTD trading as PARAMOUNT COLLECTIONS Level 2, 66 Nicklin Way or PO Box
More informationAGREEMENT FOR JBT ONLINE BILL PAY SERVICE
AGREEMENT FOR JBT ONLINE BILL PAY SERVICE INTRODUCTION This is your bill paying agreement with JONESTOWN BANK & TRUST CO. (JBT). JBT Online Bill Pay Service ( Service ) allows you to direct JBT to make
More informationAir BP Credit Application
Air BP Credit Application If filling in this form manually, please take care as cross outs or white out on the application will not be accepted. Please mail completed Credit Application forms to: Sales
More informationFACILITY TERMS & CONDITIONS
Page 1 of 7 Welcome to Leisure Management Services Pty Ltd ABN [25 069 169 482] trading as BFit Express Fitness Centre ( BFit Centre ). As a condition to membership at BFit Centre, you are agreeing to
More informationBoat Insurance Renewal
boat insurance application CGU Marine Insurance A Division of CGU Insurance Limited ABN 27 004 478 371 Please read the following information carefully. Tear off this page and keep for your reference. Your
More informationInternet and Phone Banking. Terms and Conditions and Important Information
Internet and Phone Banking Terms and Conditions and Important Information Effective Date: 20 March 2013 This booklet sets out terms and conditions for Bank of Melbourne Internet and Phone Banking, along
More informationContact AMP You can call or fax a Customer Service Officer on Phone 131 267 Fax 1300 301 267
getting a home loan? Easy cover for you Loan Cover Product Disclosure Statement Issue 3, 1 January 2012 Loan Cover is issued by AMP Life Limited ABN 84 079 300 379, AFS Licence No. 233671 Loan Cover is
More informationTravel Money Terms and Conditions ver. 1.7 (with effect from September 2, 2013)
Travel Money Terms and Conditions ver. 1.7 (with effect from September 2, 2013) This Product and related services are made available to you, the customer by ICICI Bank UK PLC ( ICICI Bank ) as per the
More informationService Level Agreement
Agreement entered into between: SOSiT (PTY) Ltd (Reg. No.: 2012/099651/07) Service Level Agreement And CC / (Pty) Ltd / Sole Proprietor Registration / Identity no: herein represented by: duly authorised
More informationAPPLICATION FOR COMMERCIAL TRADING ACCOUNT UNINCORPORATED ENTITY
APPLICATION FOR COMMERCIAL TRADING ACCOUNT UNINCORPORATED ENTITY PART A: BUSINESS DETAILS ARE YOU: a Sole Trader a Partnership A.B.N. FULL TRADING NAME: TRADING ADDRESS: POSTCODE: DELIVERY ADDRESS : BUSINESS
More information117 Cimitiere Street, Launceston, Tasmania 7250 Phone: (03) 6333 3678 Fax: (03) 6331 3972 rentals@bushby.com.au www.bushby.com.au
Tenancy Application 117 Cimitiere Street, Launceston, Tasmania 7250 (03) 6333 3678 Fax: (03) 6331 3972 rentals@bushby.com.au www.bushby.com.au This tenancy application cannot be processed until ALL pages
More informationAmerican Express. Credit Card Conditions, Financial Services Guide and Credit Guide. December 2010 AU027108E
American Express Credit Card Conditions, Financial Services Guide and Credit Guide December 2010 AU027108E Postal Address American Express Australia Limited Cardmember Services GPO Box 1582 Sydney NSW
More informationPay-by-the-month insurance. Application form
Pay-by-the-month insurance Application form Pay-by-the-month insurance Select your payment method With GIO pay-by-the-month you can smooth out your business cash flow by paying over 12 months, direct through
More informationSASC Direct Debit Instalment Plan For School Fees & Charges APPLICATION FORM
SDNE ANGLICAN SCHOOLS CORPORATION SASC Direct Debit Instalment Plan For School Fees & Charges PO BOX 465, HURSTVILLE BC NSW 1481 P (02) 8567 4004 F (02) 9580 3316 E accountsreceivable@sasc.nsw.edu.au APPLICATION
More informationOnline Multi-Currency Account Application
Online Multi-Currency Account Application Please use this application form to apply for an Online Multi-Currency Account. This account is issued by ANZ Bank New Zealand Limited ( Bank ), and managed by
More informationANZ Online Multi-Currency Account Application
Please use this application form to apply for an Online Multi Currency Account. This account is issued by ANZ Bank New Zealand Limited ( Bank ), and managed by ANZ New Zealand Securities Limited ( ANZ
More informationBENDIGO AND ADELAIDE BANK GROUP
HomeLend Line of Credit (Unregulated) Home Loan Booklet National Mortgage Market Corporation Pty Ltd ABN 52 006 325 640 120 Harbour Esplanade, Docklands Vic 3008 Phone: 1800 061 091 Fax: (03) 8414 7252
More informationGuest Profile. Smart Start
1111 Bagby St. Houston, TX 77002 713-651-0075 hfitness@plusone.com Monday Thursday: 5:30AM 9:00PM Friday: 5:30AM 8:00PM Saturday: Closed Sunday: Closed Guest Profile Mr. Ms. First Name: Last Name: of Birth:
More informationUNIT TRUST INVESTMENT APPLICATION FORM Companies, Close Corporation and other legal entities
UNIT TRUST INVESTMENT APPLICATION FORM Companies, Close Corporation and other legal entities Namibia Unit Trust Managers Limited Registration Number: 96/308 All sections must be completed in full using
More informationSENSIS CORPORATE HEALTH PLAN
SENSIS CORPORATE HEALTH PLAN The Health Insurer - Navy Health The health insurer for the Sensis Health Plan is Navy Health - a not-for-profit, member based Fund. Navy Health is one of Australia s restricted
More informationBendigo Rewards. Terms & Conditions. 21 December 2015. www.bendigobank.com.au
Bendigo Rewards. Terms & Conditions. 21 December 2015 www.bendigobank.com.au Bendigo and Adelaide Bank Limited The Bendigo Centre Bendigo VIC 3550 Telephone 1300 BENDIGO (1300 236 344) ABN 11 068 049 178.
More informationBusiness Banking Online application.
Business Banking Online application. This application will register you to Business Banking Online and allow you to: Access accounts held by ONE company or business entity Process Credit Direct Entry file
More informationCredit Cards. Conditions of Use. making banking easier
Credit Cards 1 Conditions of Use Privacy Statement and Consent to Use Your Information 25 May 2015 making banking easier About these Conditions of Use Your Card Contract comprises: (1) these Conditions
More informationInsurance Personal Questionnaire
Insurance Personal Questionnaire Name of Client 1: Name of Client 2: This section is completed by your Adviser Adviser Name: Adviser Code: Interview Date: FSG Version Number Provided: Adviser Profile Number
More informationAttachment A to Corporate Cash Management Services Agreement COMMERCIAL BILL PAYMENT SERVICES TERMS AND CONDITIONS
Attachment A to Corporate Cash Management Services Agreement COMMERCIAL BILL PAYMENT SERVICES TERMS AND CONDITIONS This Attachment A to the Corporate Cash Management Services Agreement between NewDominion
More informationThis Agreement shall be governed by and construed in accordance with the laws of the State of Wyoming.
Online Agreement: Online Banking Agreement. By submitting this form, you agree that you have read and agree to all terms herein. If you would like to talk with us about your enrollment, please call 307-732-BOJH
More informationmerchant application form
merchant application form standard & Point Of Sale (POS) Version 3.1 revised 28 February 2011 copyright mhits Limited 2004-2011 ABN 82 107 753 613 Instructions: 1. Fill in the Application Form 2. Sign
More informationInvestment & Transaction Accounts
Bankwest Investment & Transaction Accounts Terms and Conditions 25 May 2015 making banking easier Terms and Conditions These Terms and Conditions apply to all Investment and Transaction Accounts with us
More informationONLINE BANKING AGREEMENT AND DISCLOSURE
ONLINE BANKING AGREEMENT AND DISCLOSURE REDNECK BANK, A DIVISION OF BANK OF THE WICHITAS P.O. BOX 852 MUSTANG, OK 73064 Redneck Bank & Bank of the Wichitas are the same financial institution. Deposits
More informationLAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM
LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM SECTION 1 PERSONAL DETAILS Mr. Mrs. Ms. Date of birth: First Name: Surname: Address: Contact Numbers: Home Work Mobile Email SECTION 2 MEMBERSHIP
More informationDiners Club Corporate Travel System Terms and Conditions
Diners Club Corporate Travel System Terms and Conditions Contents 1 Definitions 4 2 Accepting these Terms and Conditions 7 3 Authorised Users and Authorised Cardholders 7 4 Authorised Travel Agents 7
More informationChecklist. To ensure the smooth and quick processing of your application please check the following areas have been completed.
Checklist To ensure the smooth and quick processing of your application please check the following areas have been completed. If you are an individual/non-commercial customer please complete the following
More informationBusiness ADSL2+ Autopay Application
Business ADSL2+ Autopay Application For help completing this form, please call us on (local call) Section 1: Contact and Service Address Details Company Name (must be same as phone bill) Contact Name Street
More informationApplication for Credit (Business Account)
Application for Credit (Business Account) APPLICANT INFORMATION Structure Public Company Proprietory Company Sole Proprietor Partnership Company Trading As Trustee for ACN / ABN Phone Fax Mobile Email
More informationOur standard terms and conditions for Your Advanced Personal Loan.
Our standard terms and conditions for Your Advanced Personal Loan. For loans approved on or after 6 June 2015 6 June 2015 Important Information The information set out below forms part of your disclosure
More informationONLINE EXPRESS INTERNET BANKING CUSTOMER AGREEMENT
ONLINE EXPRESS INTERNET BANKING CUSTOMER AGREEMENT This Agreement is entered into between Farmers Trust & Savings Bank (the "Bank") and any customer of the Bank who subscribes to the Bank s Online Express
More informationINBOUND 13,1300 & 1800 VOICE SERVICES
1 Why use a 13,1300 or 1800 Number? Create a professional national image and feel to your business Broaden your customer reach by providing a national number Increase & track your sales marketing responses
More informationAVA - Diners Club Business Card Application
AVA - Diners Club Business Card Application Please provide ALL information requested to avoid delays in processing the application. Please complete this form in BLACK pen and BLOCK CAPITALS. Before completing
More informationMerchant Application. FAX BACK TO: 03 9413 1467 EMAIL TO: Merch.Support@UnitedCard.com.au POST To: PO Box 1028, Collingwood, Vic 3066 THE AGREEMENT
Merchant Application FAX BACK TO: 03 9413 1467 EMAIL TO: Merch.Support@UnitedCard.com.au POST To: PO Box 1028, Collingwood, Vic 3066 THE AGREEMENT 1. The Applicant acknowledges and agrees that this United
More informationAccount Application Form
Business Customers Company/Business Name: A.B.N: Business Address: State: Postcode: Postal Address: State: Postcode: Business Phone Number: Business Fax Number: Individual Customers (Authorised Contact
More informationHSBC s Credit Card Rewards Program. Terms and conditions HSBC Premier World MasterCard
HSBC s Credit Card Rewards Program Terms and conditions HSBC Premier World MasterCard Rewards Plus Program The meaning of words printed like this and some other key words is explained at the end of these
More informationCONDITIONS OF USE for GREATER CREDIT CARDS
Head Office: 103 Tudor Street, Hamilton NSW 2303 PO Box 173, Hamilton NSW 2303 Phone: 1300 651 400 Fax: (02) 4921 9112 Web: www.greater.com.au Email: webenquiry@greater.com.au ABN 88 087 651 956 Australian
More informationBusiness Corporate MasterCard
1 Business Corporate MasterCard Terms and Conditions 25 May 2015 Contents 1. Definitions 1 2. Code of Banking Practice 5 3. About your contract 5 4. Opening the Facility 7 5. Activation and acceptance
More informationClaim Form TRAVEL INSURANCE
ACCIDENT & HEALTH INTERNATIONAL Claim Form TRAVEL INSURANCE Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS
More informationX NSW/ACT X NT X QLD X SA X TAS X VIC X WA
1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave a gap between words.
More informationFuneral Protection. Product Disclosure Statement and Policy Document. The Power of We. Version 1. Issued 15 August 2011 AIA.COM.AU
1 Funeral Protection Product Disclosure Statement and Policy Document Version 1 Issued 15 August 2011 The Power of We AIA.COM.AU About this booklet We suggest that you keep this booklet in a safe place.
More informationGraphics Online (314011) Direct Debit Request (DDR)
Graphics Online (314011) Direct Debit Request (DDR) You may contact us as follows: Phone: (07) 5503 0477 Email: accounts@graphicsonline.com.au All communication addressed to us should include your Customer
More informationTerms of Business. Murray & Spelman Ltd. Name: T/A Murray # Spelman Insurance & Finance. Name & Contact Details:
Terms of Business Murray & Spelman Ltd T/A Murray # Spelman Insurance & Finance Name & Contact Details: Name: Mr. Michael Culhane (Managing Director) Telephone Number: 091759500 Company Murray & Spelman
More informationProfessional Indemnity Proposal
Professional Indemnity Proposal IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure. Before you take out insurance
More informatione-banking Telegraphic Transfer Terms & Conditions. 1 December 2015
e-banking Telegraphic Transfer Terms & Conditions. 1 December 2015 Bendigo and Adelaide Bank Limited The Bendigo Centre Bendigo VIC 3550 Telephone 03 5485 7911 ABN 11 068 049 178. AFSL/Australian Credit
More informationONLINE SAVINGS ACCOUNT.
ONLINE SAVINGS ACCOUNT. TERMS AND CONDITIONS. THE FINE PRINT. All the details to keep everyone smiling. ABOUT THIS BOOKLET. Congratulations on choosing an Online Savings Account with ME Bank. We know that
More informationCARIBBEAN COMMERCIAL BANK (ANGUILLA) LTD. INTERNET BANKING SERVICE AGREEMENT ~ PERSONAL
I. General Terms and Conditions A. Introduction CARIBBEAN COMMERCIAL BANK (ANGUILLA) LTD. INTERNET BANKING SERVICE AGREEMENT ~ PERSONAL This Internet Banking Service Agreement ("Agreement") governs the
More informationCREDIT ACCOUNT APPLICATION 30 DAYS
CUSTOMER DETAILS CREDIT ACCOUNT APPLICATION 30 DAYS Ramaco Pty Ltd ATF The Anderson Family Trust T/A (ABN 17 854 733 680) 46-48 Yumborra Road DALBY QLD 4405 Ph: 07 4662 3866 Fax: 07 4669 6394 admin@afgrifoodsaustralia.com.au
More informationPERSONAL ACCIDENT & ILLNESS APPLICATION FORM
Adelaide Office 277 Magill Road Trinity Gardens SA 5068 PO Box 309 Kent Town SA 5071 Phone: (08) 8291 2300 Fax: (08) 8333 0034 DX: 426 PERSONAL ACCIDENT & ILLNESS APPLICATION FORM Client Details Name of
More informationApplication for health insurance. HCF Membership No. R20762. b) Choose your cover requirement (Please mark X )
Application for health insurance (Please mark X ) Join HC health fund new to private health insurance (complete sections 1-8, excluding 7) Transfer to HC health fund from another fund (complete sections
More informationBCPay. Alternative payment process when Online Banking is experiencing Operational Disruptions. Product Disclosure Statement
BCPay Alternative payment process when Online Banking is experiencing Operational Disruptions Product Disclosure Statement Effective as at 18 September 2006 Page 1 of 6 Westpac Banking Corporation ABN
More informationApplication for Business Finance
Application for Business Finance MAS, FREEPOST 884, PO Box 13042, Johnsonville, Wellington. Phone 0800 800 627. Facsimile (04) 477 0109 This section to be completed on behalf of all Applicants Lender details
More informationYour People, Protected. Sports group Personal Accident Claim Form
Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this
More informationFitness Centre Terms and Conditions
Fitness Centre Terms and Conditions Welcome to the Kogarah Wellness Centre gym. To ensure that Pinnacle Health Group able to provide a safe and comfortable environment for all members and staff please
More informationcredit cards Our terms and conditions for Your credit card
credit cards Our terms and conditions for Your credit card Contents PAGE 4 Introduction and Definitions Scope Agreement Read these Terms and Conditions Over-riding laws Guarantees as to service Interpretation
More informationVisa Credit Card Application
Visa Credit Card Application How did you hear about our Credit Card product? Primary Member No. (if applicable) Joint Member No. (if applicable) Your Credit Card Details Is this application to increase
More informationTuition Online Banking Agreement and Disclosure
Tuition Online Banking Agreement and Disclosure I. TUITION ONLINE BANKING Please read carefully the Tuition Online Banking Agreement for First Bank and Trust's ( FBT ) Tuition Online Banking system. The
More informationIP AUSTRALIA B2B ONLINE TRANSACTION SYSTEM AGREEMENT
IP AUSTRALIA B2B ONLINE TRANSACTION SYSTEM AGREEMENT Name of Customer: (The Customer) A.C.N. A.B.N. IPA Customer Number Telephone Fax Email Physical Address Postcode Mail Address Postcode Name of the Customer
More information(The issue of this form is not an admission of liability) Trust Name: JLT (CSI Member Benefits) Discretionary Trust Arrangement ABN: 56 279 303 288
1 (The issue of this form is not an admission of liability) Trust Name: JLT (CSI Member Benefits) Discretionary Trust Arrangement ABN: 56 279 303 288 This form should be completed and forwarded to - Echelon
More informationStockbroking. INDIVIDUAL/JOINT ACCOUNT application form. Please only use this form to open a trading account: in your name, or in joint names
Stockbroking INDIVIDUAL/JOINT ACCOUNT application form Please only use this form to open a trading account: in your name, or in joint names In order to process your application we will need: your completed
More informationCertificate of Entitlement (COE) Bidding Agreement. VENDOR S NAME (Addresses and details of Head Office and Branch Office)
Certificate of Entitlement (COE) Bidding Agreement VENDOR S NAME (Addresses and details of Head Office and Branch Office) THIS PURCHASER S REQUEST AND AUTHORISATION TO BID FOR A COE AGREEMENT ("the Agreement")
More information