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      *Required Field

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 I agree all the agreements listed in the above links.

Notes:

1. In the box marked "Debtor Reference" please  fill in identifying reference between the debtor and the party to be credited i.e. Gas Account Number, etc. This reference must be consistent with the Debtor Reference on the collection list.

2. If the amount of your each payment is likely to vary from time to time, please set the Limit For Each Payment at the maximum amount you would expect to pay at any one time. If "Limit for Each Payment" is not specified, the debtor's bank will set the limit as "unlimited".

3. This Direct Debit Authorisation will be cancelled automatically on the date indicated in the box marked "Expiry Date". if you wish the Direct Debit Authorisation to have effect indefinitely until further notice, please leave the box blank.