Customer Direct Debit Payment Sheet (doug douglas`s conflicted

Eazipay Ltd re Avon Valley
Adventure & Wildlife Park
Please fill in the whole form using a ball point pen.
Direct Debit Payments
Please ensure ALL details below are completed clearly and in full, in BLACK ink and
BLOCK CAPITALS in order for your membership to be processed without delay.
If you need any help completing this application form please ask a member of staff or call
01179864929.
Eazipay Ltd re Avon Valley Adventure & Wildlife Park
Pixash Lane
Bath Road
Keynsham
BS31 1TP
Bank/Building Society account number
Please sign the declaration below –
Branch Sort Code
Name and full postal address of your Bank or Building Society
To: The Manager
……………………………….…………………………………………………………….…………
Address
6
9
5
9
4
5
Instruction to your Bank or Building Society
Name ……………………………………………………………………………………….............
Address…………..……………………………………………………………………….…………
Service User Number
FOR Eazipay Ltd re Avon Valley Adventure & Wildlife Park OFFICIAL
USE ONLY
This is not part of the instruction to your Bank or Building Society.
Name(s) of Account Holder(s)
Please complete the Direct Debit form and then hand it in at the Entrance.
Please note payments will be debited from your bank account under the name
‘Avon Valley Adventure & Wildlife Park’.
Your first month’s payment is due at the time of application by cash, cheque, or
debit/credit card. Please note that there will be an £11.00 charge added to this initial
payment for the Direct Debit service, which covers all costs associated with the collection
and maintaining of this service.
Instruction to your Bank or Building
Society to pay by Direct Debit
Bank/Building Society
Please pay Eazipay Ltd re Avon Valley Adventure & Wildlife Park Direct
Debits from the account detailed in this instruction subject to the
safeguards assured by the Direct Debit Guarantee. I understand that this
instruction may remain with Eazipay Ltd re Avon Valley Adventure &
Wildlife Park and if so, details will be passed electronically to my
Bank/Building Society.
Signature(s)
Email …………………………………….………………………………………………..…………
Tel ……………………………………………………………………………………………………
‘I agree to commit to making 11 monthly payments to ‘Avon Valley Country Park Ltd’. I
accept the terms and conditions of membership and understand that if I prematurely
cancel this direct debit legal action will be taken against me by ‘Avon Valley Adventure &
Wildlife Park’ and I will be banned from the park.
Reference
Date
Banks and Building Societies may not accept Direct Debit Instructions for some types of account.
Signature
For Staff Use
Postcode
ID checked Y/N
Proof of address checked
Y/N
This guarantee should be detached and retained by the Payer.
First Payment Made =
£………...........
The Direct Debit Guarantee
Number Yearly Entry Passes Sold –
Adults=
Staff Name:
Child=
Concession=
Toddler=
! This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
! If there are any changes to the amount, date or frequency of your Direct Debit Eazipay Ltd re Avon Valley Adventure & Wildlife Park will notify you 5 working days
in advance of your account being debited or as otherwise agreed. If you request Eazipay Ltd re Avon Valley Adventure & Wildlife Park to collect a payment,
confirmation of the amount and date will be given to you at the time of the request
! If an error is made in the payment of your Direct Debit, by Eazipay Ltd re Avon Valley Adventure & Wildlife Park or your bank or building society you are entitled to
a full and immediate refund of the amount paid from your bank or building society
If you receive a refund you are not entitled to, you must pay it back when Eazipay Ltd re Avon Valley Adventure & Wildlife Park asks you to.
! You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.