Paperless Direct Debit

Please fill in your details below to pay your Intercoll debt by direct debit.
Note: All fields are required.
Intercoll Reference Number
Your details
Full Name
Birthdate
Month - Day - Year

Address

Daytime Telephone Number
Mobile Number
Email
I agree that any communications or notices including statements of account and documents for service (including legal proceedings) under this payment arrangement may be sent to the email address I have provided here. I agree to advise Intercoll if this email address changes.
Your bank details
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.
Name of Bank Account Holder
Bank Account Number
Name of Bank
Name of Branch
Bank Address
City
Name of authorised signatory
About Your Payment
When will your payments commence?

Your payments will commence no less than 10 working days and no more than 30 working days from the date you specify below.
Datetime
Day - Month - Year
How often would you like us to collect your payments?
Frequency
How much would you like to pay (each period)?
Amount ($)
Declaration
By signing up to this paperless authority, I authorise Intercoll Ltd using Authorisation code 0216807, 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*
DateTime

Your details