Direct Debit Mandate Form

Attention: open in a new window. PDFPrint

CJOLoughlin Logo

Company Name:
Registration Number if Ltd.:
Telephone No.: Fax. No.:
VAT No.:
Registered Office Address: Order Contact:
Invoice Address: Accounts Contact:
Proprietary / Partnership:
Home No. / Address:
Trade References (Please provide name, address and telephone no. for each)
1.
2.
3.

4. Your instructions to the bank and signature I instruct you to pay direct debits from my account at the request of C.J. O’Loughlin & Sons (Courtown) Ltd

  • The amounts are variable and will be debited on or just after the 28th day of each month.
  •  I understand that C.J. O’Loughlin & Sons (Courtown) Ltd. may change the amount and date only after giving me prior notice.
  • I will inform the bank in writing if I wish to cancel this instruction. 
  • I understand that if any direct debit is paid which breaks the terms of this instruction, the bank will make a refund.

Bank Details:
Name:
Address:
Account No.: Sort Code:
A copy of your letterhead and proof of address (copy of recent utility bill, drivers licence etc.) must accompany this application
Signed: Dated:
Position: