Bridge for Asylum Seekers Foundation

	Direct Debit Request UnitingCare NSW ACT Bridge for Asylum Seekers Foundation Account No. 52291 S6
Request and Authority to debit the account named below to pay: The Uniting Church (NSW) Trust Association
Request and Authority to debit	Surname or company name _______________________________________ Given names or ACN/ARBN __________________________________("you") request and authorise The Uniting Church (NSW) Trust Association [Debit User Number 003782] to process any amount The Uniting Church (NSW) Trust Association deems to debit or charge you through the Bulk Electronic Clearing System from an account held at the Financial Institution below subject to the terms and conditions below
Name of Financial Institution that holds the account to be debited	Financial Institution Name _________________________________________ Address _______________________________________________________
Details of account to be debited.	Account Name ___________________________________________ BSB Number - Account Number
Acknowledgement	By signing this Direct Debit Request you acknowledge having read this and understand the terms and conditions under which debit arrangements are made between you and The Uniting Church (NSW) Trust Association as laid down in this Direct Debit Request and in your Direct Debit Request Service Agreement.
Optional Information Please tick one box.	The maximum amount to be debited at any one time is: $_____________ / ____________________________(amount in words) OR The first debit may be made on ____/____/____ and at once only/ weekly/ fortnightly/ monthly/ quarterly/ half yearly intervals thereafter. (please circle) OR Debits may be made fourteen days after the issue of a billing advice.
Signature and address of account holder(s)	Signature (1)_______________________(2)_________________________ Address _____________________________________________________ ________________________________________ Date _____/_____/_____