Request and Autohority to Debit
Fields marked with asterisk * are compulsory
Surname or Company name* ►
Given names or ACN/ARBN* ►
I, ,
request and authorise IntelliTrac Pty. Ltd. trading as IntelliTrac user Identification Number 324439 to arrange through
its own financial institution for any amount IntelliTrac Pty. Ltd. trading as IntelliTrac may debit or charge you to be
debited through the Bulk Electronic Clearing System from an account held at the financial conditions of the Direct
Debit Request Service Agreement and any further instructions provided below.

We agree that IntelliTrac is authorised to increase the amount on our existing Direct Debit Authority to cover the cost
of the GPS devices, accessories, services and monthly fees for this order. The Direct Debit Authority will continue to be
accessed for the duration of this contract under the terms and conditions of sale and as long as the service is provided by
IntelliTrac beyond the contract date.
Insert the name and address of
financial institution at which
account is held
Financial institution name* ►
Address ►
Insert details of account to be
Name of account* ►
BSB number* ► -  
Account number* ►  
For each box above, type in directly the figure desired (0-9), the cursor will move to next box automatically.
To correct a number type in to overwrite. Spaces will be turned into zeroes
Acknowledgement By signing this Direct Debit Request you acknowledge having read and understood the terms and conditions
governing the debit arrangements between you and IntelliTrac Pty. Ltd. trading as IntelliTrac as set out in this
Request and in your Direct Debit Request Service Agreement.
Payment details
The First Monthly Direct Debit Amount is ► $   ¢
Continuing Monthly Direct Debits Amounts are ► $   ¢
Monthly Direct Debits remain in force for a minimum period of
►   Months
or until you notify in writing of your intention to terminate this agreement
and any other relevant agreements pertaining to this direct debit request.
Insert your signature and your address Insert your signature here ►  
If signing for a company, print full name and capacity for signing, below:
Name and surname*     Capacity for signing (e.g. Director)*
Insert your address here* ►
Date ►  /   / 
Alternatively, you can download the pdf form here.
Complete the form manually, sign and send it back to us by fax to 03 9466 7188.