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
Day - Month - Year

Address

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

Daytime Telephone Number
Mobile Number
WINZ Client No. (if applicable)
Employer Name and Address (if applicable)
Email
Declaration
I agree that any communication or notices including statements of account and documents for service (including the service of legal proceedings) under this payment arrangement may be sent to the email address I have provided here or the postal address (including PO Box) that I have provided above. I agree to advise Intercoll if either my email address or my postal address change.
Alternate Contact Details
Next of Kin 1
Full Name and Address
Phone Number
Next of Kin 2
Full Name and Address
Phone Number
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 and Branch
Name of authorised signatory
About Your Payment
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.
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

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)?