Direct Debit application form

About you

Your name:

Your address:

Your email:

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, allpay Limited will notify you 3 working days in advance of your account being debited or as otherwise agreed.
If you request allpay Limited 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 allpay Limited 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 allpay Limited 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.

Confirm agreement

I agree to the Direct Debit Guarantee above

Name of account holder:

Name of bank or building society:

Account number:

Sort code:

Monthly direct debit amount:

Consent for storing submitted data

Yes, I give permission to store and process my data