Gurranabraher Credit Union Ltd
Debit Card Payment Plan – Customer Not Present
Tenant Number
The Card holder must be the person on the phone authorising the payment plan.
The Card holder must be a member of Gurranabraher Credit Union Ltd.
Cardholder Name
Card Type
Laser
Visa Debit
MasterCard
Weekly
Fortnightly
Monthly
Payment Amount
Payment Frequency
Date of First Payment
Account for payment
Card Number
Card Expiry
/
CSV
Verification Questions
Asked
Verified
Card Holders Name
Card Holders Address
Card Holders Date of Birth
Card Holders Phone Number
Account balance or recent transaction
Script
I confirm that I am the cardholder of the card details provided. I hereby authorise
Gurranabraher Credit Union Ltd to set up and operate a debit card payment plan to
debit the specified card number in the payment amount specified at the payment
frequencies specified and for the number of payments specified, and to credit these
payments to the Account specified.
Verification Questions Passed &Verbal Consent received from:
Member
Consent Acknowledged
Signed
Members Name
Yes
Tick
No
Tick
Staff members signature
Date
Date of consent
Time
Time of consent
For Office Use Only
Completed by
Entered on RMS by
Checked by
Date
Date
Date
Version: Feb 2014
Gurranabraher Credit Union Ltd
Debit Card Payment Plan – Customer Not Present
Version: Feb 2014