Customer Ref:
Schedule
Termination:
Until further notice
Personal Details
Company name
Title
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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
Additional Reference:
*
If you are setting up a Direct Debit for Council Tax, please confirm which date you would like your Direct Debit payment to be taken:
1st
8th
18th
28th
*
What address does this Direct Debit payment relate to:
*
Instruction to your Bank or Building Society to pay by Direct Debit
APS Re Orkney Council, Council Offices, School Place, Kirkwall, Orkney, KW15 1NY
Service User Number:
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.