Paperless Direct Debit

Intercoll Reference Number

Full Name

Address

Street Address
Street Address 2
Suburb	City/Region
Post Code	Country

Mobile Number

WINZ Client No. (if applicable)

Full Name and Address

Phone Number

Authorisation

I confirm that I have sole authority for the bank account I will be submitting. If there is more than one signatory on the account, a direct debit form will need to be signed. Please contact us at admin@intercoll.co.nz to request a printed direct debit form.

Bank Account Number

Name of authorised signatory

When will your payments commence?

Your payments will commence no less than 2 working days and no more than 30 working days from the date you specify below.

How often would you like us to collect your payments?

How much would you like to pay (each period)?

Declaration

By signing up to this paperless authority, I authorise Intercoll Ledger Limited using Authorisation code 0235575, until further notice to debit my account with all the amounts the initiator may initiate by Direct Debit.
I accept the terms and conditions of this Authority which can be found here*

I agree that any communications, notices, statements of accounts, disclosures (including any required under the Credits Contracts and Consumer Finance Act 2003) or documents for service ( including the service of any legal proceedings) in connection with: a) this payment arrangement, b) any other payment arrangement, loan, or other debt owed to the Intercoll Group (whether by assignment or otherwise), whether entered into before or after this payment arrangement: and c) any other payment arrangement, loan, or other debt that the Intercoll Group may be collecting on behalf of a third party whether entered into before or after this payment arrangement, may be validly served to either the email address or postal address (which may include a post office box address) I have provided below.

I agree to advise Intercoll Group of any changes to my email address or postal address and that, if I fail to do so, I will still be treated as having received copies of all relevant documents provided to an address listed below

Alternative Email

Alternative postal address

Paperless Direct Debit

Your details

Alternate Contact Details

Next of Kin 1

Next of Kin 2

Bank Details

About Your Payment

When will your payments commence?

How often would you like us to collect your payments?

How much would you like to pay (each period)?