Direct Debit Form

Member no:

Account Information

Account Name

Account Number

Bank and Branch (6-digits)

valid

Account (7-digits)

Suffix (2 or 3 digits)

Your Statement Details

Particulars

Code

Reference

Payment Details

Interval

Gross Annual Income

Amount

Start Date

By ticking here, I

confirm I can operate and have sole authority on the nominated account number
confirm that I have read and accept the direct debit terms and conditions
confirm that the direct debit is also subject to my bank's standard terms and conditions that relate to my account
agree to receive confirmation of the sign up to direct debits (within 5 business days) and notifications for ongoing payments to the email address provided

Should two signatures be required please download a paper form and send us the signed form.

For any questions, please contact us on 0508 367 772 (option 2) or email us at support@psa.org.nz

Signup and Continue Cancel

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

We have detected a pending verification for this email address. Please wait while we process it. We will contact you using the details you provided. If you prefer, you can also reach out to our support team to follow up on your verification status.

In the meantime, feel free to visit our website for the latest news and upcoming events.