Nelson Media Access Trust Inc. Box 2108 Stoke Nelson 7041 New Zealand Tel: 03 544 7929 Email: btv27@Beacon27.org.nz Web: www.Beacon27.org.nz 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

B

e

a

c

o

n

2

7

Code

Payer’s Name

D.	AUTHORISATION
	1. Please make this automatic payment as detailed by debiting My/Our account. 2. I/We understand and accept that the Bank accepts this authority only on the conditions overleaf.
	Name of Account:	_____________________________
	Customer Signature:	_____________________________
	Date:	_____/_____/_______

E.

CONDITIONS

the Bank will use reasonable care and skill to give effect to the directions given to it in this authority where the directions given in this authority have been given by me/us for the purpose of a business, the Bank accepts those directions without any responsibility or liability for any refusal or omission to make all or any of the payments or for late payment or for any omission to follow such directions the Bank accepts no responsibility or liability for the accuracy of the information contained in the payment information fields on this authority I/We undertake to advise the Bank immediately of any information about payments shown on bank statements which is incorrect this authority is subject to any arrangement now or hereafter subsisting between Myself/Ourselves and the Bank in relation to My/Our account the Bank may in its absolute discretion conclusively determine the order or priority of payment by it of any monies pursuant to this or any other authority or cheque which I/We may now or hereafter give to the bank or draw on My/Our account the Bank may in its absolute discretion refuse to make any one or more payments pursuant to this authority where there are insufficient funds available in My/Our account this authority may be terminated or reduced by the Bank or the Payee without notice to Me/Us in respect of the payments detailed over this authority will remain in force and effect until notice or My/Our death or bankruptcy or other revocation is received by the Bank all current Bank and Government charges for this service in force from time to time are to be debited to My/Our account.

F.	ALTERATION TO REGULAR AMOUNT
	Please alter the regular amount of this automatic payment
	New Amount: $ _____________._____		Amount in words: _________________________________
	____________________________________________________________________________________
	As From Date:	_____/_____/_______
	Customer Signature:	_____________________________