EzyPay Form

EzyPay Online Form

Name *

First

Last

Email *

Contact Phone *

Postal Address

Date of Birth

Payment Information *

Recurring Payment
One off Payment

Amount *

Please note that the minimum recurring payment amount is $25 per week

Frequency

Monthly
Fortnightly
Weekly

Start Date

Payment Method

Bank Account
Credit/Debit Card (we will call you to take details over the phone)

BSB & Account Number

Terms and Conditions Please Enter Initials to Indicate You've Read Them

You will be charged by our third-party billing service Ezipay on a weekly basis. You can find the details of the company below. Should you need to change your credit card details please do let us know in advance as there is a failed payment fee of $9.79 which charged. you can contact directly or call Ezpay on the number below. $0.36 + 1.7490% of the debit amount is charged for every transaction Customer Service Hotline Hours: 8am – 6pm (AEST) Australia | 1300 300 553 | help@ezypay.com New Zealand | 0800 399 420 | nz.help@ezypay.com

Signature

I have read and understood the terms and conditions listed above and consent to EziPay deducting the agreed amount on the agreed date as listed above.

Name

Date