Membership - Payment Variation Form

Membership – Change of Payment Information

"*" indicates required fields

Member Details

Member Full Name:*

Please provide your Full Name as stated on your membership.

Phone Number:*

Email Address:*

Residential Address:*

Street Address State / Province / Region ZIP / Postal Code

Birth Date:*

New Payment Information

Please choose which payment method you would like us to debit your future membership payments from. Please ensure that all details are 100% accurate.

Direct Debit:

Name of Account Holder

Account Type*

Cheque

Savings

BSB

Account Number:

Account Holder Signature/Authorisation:*

I Confirm that the above information is accurate & I have the authorisation to submit these details to be applied to the mentioned membership agreement as per this completed form.

Credit Card:

AMEX Accepted for payments.

Name on Card:

Cardholder

Credit Card Number:

Expiry Date:

CVC:

Card Holders Signature:*

I Confirm that the above information is accurate & I have the authorisation to submit these details to be applied to the mentioned membership agreement as per this completed form.

Acknowledgement of Payment Details Updated

This Authorisation is to remain in force in accordance with the Terms and Conditions provided on my membership agreement.

Signature:*

By signing this form, I hereby acknowledge that the information provided is accurate.

Membership – Payment Variation Form

Membership – Change of Payment Information

Member Details

New Payment Information

Direct Debit:

Credit Card:

Acknowledgement of Payment Details Updated

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