Customer Ref:
Schedule
Termination:
Until further notice
Personal Details
Title
---Select---
Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
---Other---
First name
Surname
*
Line1
Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
*
Additional Information
Fund Code:
*
Ledger Code:
*
Instruction to your Bank or Building Society to pay by Direct Debit
APS re Havant BC, Havant Borough Council Public Service Plaza, Civic Centre Road, Havant, PO9 2AX
Service User Number:
Custom Bank Reference:
Account holder name
Account number
Bank sort code
Please tick to confirm you are the only person required to sign for this account
Checking the box indicates that I am the Bank/Building Society holder and no authority other than my own is required. If more than one person is required to authorise debits from the account, you are unable to setup a direct debit online.