E-Toll Confirmation / Change of direct debit details

1. E-Toll account details
Account no. I am/We are the authorised nominated account holder/s entitled to give the commitments in this application. I/We have read and agree to be bound by the Terms and Conditions for this Roads and Maritime Services (RMS) EToll account and authorise RMS to charge the nominated account above with all fees and charges as set out in or payable under these Terms and Conditions. This authorisation is an ongoing arrangement and will remain in force until I/we cancel it. E-Toll account Terms and Conditions are available online. Visit myE-Toll at myRTA. com. Signature of nominated account holder 1

ABN (business customers only)

Account name

Date

2. Customer details
day

/

month

/

year

Customer name (If different to Account name) Signature of nominated account holder 2

Driver licence no.

Date
day

/

month

/

year

Phone password (12 characters maximum)

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)

3. Direct debit details
Complete the new direct debit account details below. Please note both the direct debit account holder and the E-Toll account owner must sign this form. Name of financial institution

BSB

Account number

Signature of E-Toll Account Owner

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

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