Credit Card Direct Debit Request
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 to debit or charge my nominated credit card each and every month
for a minimum period of    ►    months  or untill you notify in writing of your intention to terminate this agreement.
Insert details of credit card
to be debited
Type of credit card* ► Visa Mastercard
Name on credit card* ►
Credit card number* ► - - -
Expiry date* ► -   (MM-YY)
CCV* ►   (Security code on the back of your card)
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 Credit Card 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 ►  
Insert your address here* ►
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.