Sales & Support 1300 135 231  |  Contact Details

Direct Debit Form

Please fill in the form below to request and authorise e-Wire Connection Point Pty Ltd (ABN 71 154 074 218) to arrange, through its own financial institution, for any amount, e-Wire may debit or charge you under the Customer Service Agreement (CSA) to be debited from the account held by you at the financial institution identified below and paid to e-Wire subject to the terms and conditions of the CSA and the Direct Debit Agreement (and any further instructions provided below).

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Service Address *
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Please select the method you'd like to set up your direct debit. Only one method is required

Bank Details Credit Card (MasterCard or Visa)
Bank Details



Card Details Visa Mastercard


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Advisory

By signing this Direct Debit Request Form, I/We authorise ABC to charge my/our Credit Card Account (as above) as payment for my/our usage of the Services specified in my connection application form and the CSA. This authority will remain in place until e-Wire Connection Point receives written notification from me/us to cancel the arrangement.



I Agree  I do NOT agree

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