Personal Information Let us know who you are Billing Enter billing information Personal Information Full Name * Full Name is required Street Address * Address is required Mobile Phone * Your phone number is not in the valid format Phone Your phone number is not in the valid format Email Address * Your email is in the incorrect format Date of Birth * Date of birth is required Drivers License Number * Drivers License Number is required Drivers License Version * Drivers License version is required My billing address is different than the previous details Billing Details Full Name * Separate billing name is required if billing details are different Street Address * Billing address is required I am NOT the owner of this address Owners Name * Owners name is required Street Address * Owners street address is required Mobile Phone * Your phone number is not in the valid format Contract Information Contract Term * Open Term 12 Months Term 24 months Term Extra Information Customer Portal Username Customer Portal Password Preferred Wifi Name Preferred Wifi Password Agreement I agree that the company may carry out a full credit check I have read and agree with the terms of service Please agree to the terms and credit check Banking Details Account name * Bank code * Your bank code is not in the valid format Branch number * Your branch code is not in the valid format Account number * Your account number is not in the valid format Suffix * Your suffix is not in the valid format Bank account number example All New Zealand bank account numbers follow this pattern: 00 0000 0000000 000 The first two numbers show the bankcode The next four digits show your branch number The next seven show your account number The next three (or two for some banks) show your account suffix Example: The account number: 03 1234 5678901 000 Bankcode: 03 Branch number: 1234 Account number: 5678901 Suffix number: 00 Authority to accept Direct Debits The Initiator Has agreed to give advance Notice of the net amount of each Direct Debit and the due date of debiting at least 10 calendar days before (but not more than 2 calendar months) the date the Direct Debit will be initiated. This notice will be provided either: in writing; or by any other means which provides a verifiable record of the initiated transaction and where the Customer has provided prior written consent to the Initiator. The advance notice will include the following message: “Unless advice to the contrary is received from you by (*date), the amount of ($amount) will be directly debited to your Bank account on (initiating date).”* This date will be at least 2 days prior to the due date to allow for amendment of Direct Debits. May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no further Direct Debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future payments by notice in writing to me/us. OR Undertakes to give Notice to the Acceptor of the commencement date, frequency and amount at least 10 calendar days before the first Direct Debit is drawn (but not more than 2 calendar months). This notice will be provided either: in writing; or by any other means which provides a verifiable record of the initiated transaction and where the Customer has provided prior written consent to the Initiator. Where the Direct Debit system is used for the collection of payments which are regular as to frequency but variable as to amounts, the Initiator undertakes to provide the Acceptor with a schedule detailing each payment amount and each payment date. In the event of any subsequent change to the frequency or amount of the Direct Debits, the Initiator has agreed to give advance notice at least 30 days before the change comes into effect. This notice must be provided either: in writing; or by electronic mail where the Customer has provided prior written consent to the Initiator May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no further Direct Debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future payments by notice in writing to me/us. The Customer may: At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the Initiator. Stop payment of any Direct Debit to be initiated under this Authority by the Initiator by giving written notice to the Bank prior to the Direct Debit paid by the Bank. Where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has been made without notice being given in terms of clause 1 (a) above, request the Bank to reverse or alter such Direct Debit initiated by the Initiator by debiting the amount of the reversal or alteration of a Direct Debit back to the Initiator through the Initiator’s Bank. PROVIDED such a request is made not more than 120 days from the date when the Direct Debit was debited to my/our account. The Customer acknowledges that: This Authority will remain in full force and effect in respect of all Direct Debits made from my/our account in good faith notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by the Bank. In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to my/our account. Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank except in so far as the Direct Debit has not been paid in accordance with this Authority. Any other dispute lies between me/us and the Initiator. Where the Bank has used reasonable care and skill in acting in accordance with this authority, the Bank accepts no responsibility or liability in relation of: − the accuracy of information about Direct Debits on Bank statements − any variations between notices given by the Initiator and the amounts of Direct Debits. The Bank is not responsible for, or under any liability in respect of the Initiator’s failure to give written advance notice correctly nor for the non−receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies between me/us and the Initiator. Notice given by the Initiator in terms of clause 1 (a) to the debtor responsible for the payment shall be effective notice. Any communication necessary because the debtor responsible for payment is a person other than me/us is a matter between me/us and the debtor concerned. The Bank may: At its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any other order, authority, cheque or draft properly executed by me/us and given to or drawn on the Bank. At any time terminate this Authority as to future payments by notice in writing to me/us. Charge its current fees for this service in force from time to time. I agree to the conditions of this Authority to accept Direct Debits Please agree to the direct debit authority Please sign here Please sign in the box bellow using your mouse or finger if you are on mobile Submitting Thank You! Your submission was successfully submitted. 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