Co-Sponsor Automatic Payment Form
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Hearing Dogs for Deaf People New Zealand

Co-Sponsor Automatic Payment Authority

Please complete and return this form (no stamp required) to:

Hearing Dogs for Deaf People NZ
Freepost Hear Boy!
PO Box 8117 New Plymouth
Ph: 06 769 5000 Fax: 06 769 5400

BANK DIRECT CREDIT
Name of bank and branch :
Name of account to be debited:
Account number to be debited:
Amount

$
Frequency: Weekly / Fortnightly / Monthly / Other (please state)
Start Date:
Pay until: (tick preference)

 Further notice or (date:)
Pay to: Hearing Dogs for Deaf People New Zealand
12-3026-0086096-50 [ASB Bank Takapuna]
Details to appear on my statement: Hearing Dogs Donation
Information to appear on Hearing Dogs for Deaf People NZ's statement: (Surname)                                        (Initials)

DIRECT CREDIT PAYMENT: I/we understand that the bank accepts this authority only upon the conditions set out on the reverse of this authority

Name:


 Phone:
Signed:


 Fax:
Date :


 Email:

See overleaf to use your CREDIT CARD for payment.

Bank Use Only
Form accepted by:





Details loaded by:





Date:





DATE STAMP











Automatic Payment Authority conditions for Bank Direct Credit:

I/we understand and accept that the bank accepts this authority only upon the following conditions:

1. The Bank will endeavour to effect such automatic payments without any responsibility or liability for refusal or omission to make all or any of the payments or for late payment or for any omission to follow any such instructions. Further, the Bank accepts no responsibility or liability for the accuracy of the information contained in the payment information fields on this authority or failure to transmit such information in the manner requested. In any event this authority is subject to any arrangement now or hereafter subsisting between myself/ourselves and the Bank in relation to my/our account.

2. The Bank may at its absolute discretion conclusively determine the order or priority of payment by it or any money pursuant to this or any other authority or cheque which I/we may now or hereafter give to the Bank or draw on my/our account.

3. The Bank may at any time terminate this order as to future payments by notice in writing to me/us or without notice at any time after being advised in writing by the above named payee that payment is required.

4. This order will remain in full force and effect in respect of all payments made in good faith notwithstanding my/our death or bankruptcy or any other revocation of this order until notice of my/our death, bankruptcy or such revocation is received by the bank.

5. All current Bank charges for this service in force from time to time are to be debited from my/our account.





Payment by CREDIT CARD
Card Type:

 Mastercard        Visa
Card Number:
Name on credit card:
Expiry Date:
Signature:
Amount

$
Frequency: Weekly / Fortnightly / Monthly / Other (please state)
Start Date:
Pay until: (tick preference)

 Further notice or (date:)

CREDIT CARD PAYMENT: I/we hereby authorise Hearing Dogs for Deaf People New Zealand to charge my credit card for the amount specified above at the frequency specified.

Name:



 Phone:
Signed:



 Fax:
Date :



 Email: