Direct Debit Application

Please ensure that data is entered correctly

If you have problems completing this form, please contact us at bps-info@bottomline.com or telephone 0344 826 6700

Title

First name Please enter a first name

Last name Please enter a last name

Date of birth

Email address Please enter an email

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Mobile phone number

Current address

I am applying on behalf of a company

Company name

Company registration no.

Postcode Please enter a postcode

Building number or name Please enter a building name or number

Address

Town or city

Debiting plan: Subscription - Monthly

Start date Please enter a valid start date

1 Earliest Start Date is...

End of Collections Please enter a valid number of payments

Please enter a valid end date

Amount

First amount Please enter a valid first amount

Regular amount

Regular amount Please enter a valid regular amount

Last amount Please enter a valid last amount

Bank account information

Name of account holder(s) Please enter a valid bank account name

Sort code

Account number

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Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept Instructions to pay Direct Debits.
If there are any changes to the amount, date or frequency of your Direct Debit, BPS re: ESPRESSO will notify you 5 working days in advance of your account being debited or as otherwise agreed. If you request BPS re: ESPRESSO to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
If an error is made in the payment of your Direct Debit, by BPS re: ESPRESSO or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society.
- If you receive a refund you are not entitled to, you must pay it back when BPS re: ESPRESSO asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

The details of your Direct Debit Instruction will be confirmed to you within 3 working days or no later than 5 working days before the first collection.

BPS re: ESPRESSO will appear against the Direct Debit on your bank statement.

Confirm that the above Bank Account information is correct.

If two or more people are required by your bank to authorise new Direct Debits, this form cannot be used. Please contact BPS re: ESPRESSO to discuss alternatives.

Confirm that you are the Account Holder and the only person required to authorise Direct Debits from this account?

Your payments are protected by the Direct Debit Guarantee.