Direct Debit Request

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Direct Debit Request 2017-05-11T10:32:04+00:00

Direct Debit Request

Setup an automatic direct debit from your bank account today and help RACQ CQ Rescue SAVE LIVES 24/7!




If you are a BHP Employee please
click here
Set-up a monthly, quarterly, or annual direct debit to make donating to RACQ CQ Rescue easy and automatic!

* Denotes mandatory field.

Surname*:

Given name/s*:

Email*:

Phone number*:

Address*:

Town/Suburb*:

State*:

Postcode*:

Financial Institution Name*:

Name/s on account*:

BSB Number*:

Account Number*:

DEBIT ARRANGEMENT

Frequency* (please note debits occur on the 16th of the month):
MonthlyQuarterlyAnnuallyOnce only

Start month (optional):

Amount to be debited (AUD)*:
$100$50$25Other

If other, please specify amount to be debited:

Please note: Recurring debits continue until further notice. For all correspondence and changes to frequency, please Contact Us.

I/We request and authorise CQ Rescue (Direct Entry User ID 447949) to arrange, through its own financial institution, to debit my/our nominated account, any amount CQ Rescue has deemed payable by me/us.

I/We understand the debit amount will be calculated from the Debit Arrangement I/we have agreed to by completing this form.

I/We acknowledge this debit or charge will be made through the Bulk Electronic Clearing System (BECS) from my account held at the financial institution I/we have nominated and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

By submitting this form you agree to the above authorisation and the Central Queensland Helicopter Rescue Service Ltd Direct Debit Request Service Agreement.

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