Direct Debit Mandate

This form is for customers registering for Direct Debit with a partnering Organisation.

Before you apply, here are a few things we would like to make you aware off:

Customer Terms and Conditions

Customer Data Security

Website Legal Information

Privacy Policy

All compulsory fields are marked with ‘*’.

CUSTOMER DETAILS

Name *

First

Middle

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Address registered with Bank of St Helena

Email *

Telephone *

Mobile

BILLING DETAILS

Billing Organisation *

Select Applicable

Customer Reference/ Account Number *

Customer Account Name *

Customer Billing Address with Billing Organisation

Address Line 1

City

State / Province / Region

Postal Code

if different to the above address

PAYMENT DETAILS

Bank Account Number *

Bank Account Name *

AUTHORISATION

I hereby authorise the Billing Organisation to debit my account (identified above) in respect of the amounts requested under the terms of the Direct Debit Service, in accordance with the Service Terms and Conditions, until further notice by me, in writing, to Bank of St Helena Ltd. As per the Service Terms and Conditions, I agree to maintain sufficient funds within the nominated account and authorise Bank of St Helena to deduct any relevant charges should my nominated account enter into an Unauthorised Overdraft. *

Signature

If you feel your signature is not legible, you may upload it in the section below. This application cannot be accepted without a signature.

Signature Upload (if required)

Click or drag a file to this area to upload.

Date *

Captcha *

(Completely Automated Public Turing Test To Tell Computers and Humans Apart)

Name	Domain	Purpose	Expiry	Type
_ga	sainthelenabank.com	Google Universal Analytics long-time unique user tracking identifier.	2 years	HTTP
_gid	sainthelenabank.com	Google Universal Analytics short-time unique user tracking identifier.	1 days	HTTP
_gat_gtag_UA_160972869_1	sainthelenabank.com	Google Analytics	Session	---
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