Nelson Media Access Trust Inc. Box 595 Nelson New Zealand Tel: 03 539 0607 or 547 2337 Fax: 03 548 8874 Email: trust@7-media.net Web: www.7-media.net/trust Not-for-profit community TV Channel

Authority for Automatic Payments

(Not to operate as an assignment or an agreement)

A.

PAYER DETAILS

To the Manager,

Name of Bank: ___________________________________________

Branch: _________________

Address: ____________________________________________________________________________

Name of Account: _________________________________________

Important – please tick:

O

This is a new authority, OR

O

as from _____/_____/_______ (first payment date) , this authority replaces existing authorities

for $ _____________._____ in favour of the same payee

Account Details:

Bank

Branch

Account

Suffix

Name of Account:

Details to Appear on My/Our Bank Statement:

Particulars

Code

Reference

B.	Frequency and Amount:
	First Payment Date: _____/_____/_______								Last Payment Date: _____/_____/_______
	OR,	Until further notice	O		(please tick)
	Frequency (please tick):		O		Four weekly			O	Monthly	O	Specify other period
	Fixed Amount: $ _____________._____						Amount in words: _________________________________
	____________________________________________________________________________________
	Complete if applicable (tick one only):			O		Variable first amount				O	Variable last amount
	Amount: $ _____________._____						Amount in words: _________________________________
	____________________________________________________________________________________

C.

PAYEE DETAILS

Account Details:

0

6

Bank

0

7

0

5

Branch

0

3

0

7

7

7

4

Account

2

5

Suffix

Name of Account:

N

E

L

S

O

N

M

E

D

I

A

A

C

C

E

S

S

T

R

Details to Appear on Payee’s Bank Statement:

D

O

N

A

T

I

O

N

Particulars

C

H

7

Code

Payer’s Name