Professional Documents
Culture Documents
Account name
Date
2. Customer details
day
month
year
Customer name (If different to Account name) Signature of nominated account holder 2
Date
day
month
year
4. Declaration
I hereby notify a change to the direct debit details to enable continued operation of this E-Toll account with Roads and Maritime Services (RMS) for use of the Electronic Toll Collection facilities in NSW and other locations nominated by RMS. I acknowledge that this direct debit arrangement is governed by the Terms and Conditions and the Direct Debit Request Service Agreement, both of which may be varied by RMS and notified to me in writing. The details given are correct and I will notify RMS immediately of any changes to the E-Toll account. Name Name/s on account with financial institution Position (business accounts only)
BSB
Account number
Date
day
month
year
Contact Details MAIL this completed form to the Roads and Maritime Services, P.O. Box 1447, Parramatta, NSW 2124 IN PERSON present this completed form to an E-Toll motor registry (see the our website) For more information on E-Toll, phone the us on 131 865 (131 TOL) or visit myRTA.com
ABN 76 236 371 088 Catalogue No. 45071442 Form No. 1519 (03/2013) Page 1 of 1