[vc_row][vc_column] Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Consent(Required) I agree to the Direct Debit Agreement outlined below.1. By agreeing to the Direct Debit Request you authorise Stripe to arrange for funds to be debited from your nominated financial institution account (the nominated account is the Debit/Credit Card used to make payment of your course deposit). Stripe is acting as an agent for Australian College of Weight Management Pty Ltd and Stripe does not provide any goods or services to you. 2. Stripe or Australian College of Weight Management Pty Ltd will give you at least 14 days notice in writing of any changes to the terms of the drawing arrangements. 3. Stripe will keep information relating to your nominated account confidential in accordance with Stripe’s privacy policy, except where required for the purposes of conducting direct debits with your financial institution. Your personal information will be transferred by Stripe to the United States. If you do not want to provide your personal information to Stripe in connection with the Direct Debit Request, Stripe will not be able to debit your nominated account. 4. Where the due date is not a business day Stripe will draw from your nominated financial institution account on the next business day. 5. It is your responsibility to: - Ensure your nominated account can accept direct debits; - Ensure that there are sufficient clear funds available in the nominated account to meet each drawing on the due date; - Advise immediately if the nominated account is transferred or closed or your account details change; - Arrange a suitable payment method if Stripe or Australian College of Weight Management Pty Ltd cancels the drawing arrangements; - Ensure that all authorised signatories nominated on the financial institution account to be debited authorise the Direct Debit Request. 6. Subject to the terms and conditions of your nominated financial institution account and your agreement with Australian College of Weight Management Pty Ltd, you may alter the drawing arrangements. Such advice should be received by Australian College of Weight Management Pty Ltd at least 7 business days prior to the drawing date for any of the following: - Changing your nominated account number - Altering a DDR schedule If you require further information, please contact Australian College of Weight Management Pty Ltd. Alternatively, you can also contact your financial institution or confirm your financial rights. 7. If you believe that there has been an error in debiting your account, you should notify Australian College of Weight Management Pty Ltd as soon as possible. Australian College of Weight Management Pty Ltd will notify you in writing of its determination and the amount of any adjustment that will be made to your nominated account (if any). Stripe will arrange for your financial institution to adjust your nominated account by the applicable amount (if any). Alternatively, you can also contact your financial institution. 8. The details of your drawing arrangements are contained in the Direct Debit Request here. - A payment variation plan is only offered for one 12 week period at any given time and are subject to one review at the end of the 12 week period - Payment variation plans are only offered at the reduced rate of $10 per week or $20 per fortnight for a total of 12 weeks, to assist students through difficult financial circumstances - Where there has been no offer or extension of a payment variation plan in writing, any additional payments made here will be applied to your total outstanding balance and your regular direct debit will continue as such 9. Stripe reserves the right to cancel the drawing arrangements if three consecutive drawings are dishonoured by your financial institution, and for Australian College of Weight Management Pty Ltd to arrange with you an alternative payment method. Please refer to the terms and conditions of your nominated financial institution account to see whether dishonour fees apply. Australian College of Weight Management Pty Ltd may charge additional dishonour fees in accordance with your agreement with Australian College of Weight Management Pty Ltd Terms of Enrolment. Stripe Privacy Policy: https://stripe.com/au/privacy Financial Rights: https://financialrights.org.au/factsheets/direct-debits-from-credit-cards-factsheet/ ACWMAH Terms of Enrolment:https://www.collegeofweightmanagement.com.au/terms-of-enrolment/ Direct Debit Frequency(Required) Weekly Fortnightly Please Note: Drawing arrangements are set at a minimum Weekly rate but if you select Fortnightly the amount of your drawing arrangement will equal two Weekly instalments. The drawing arrangement will begin one week/fortnight from the date your deposit was paid and continue until your 12 week payment variation plan expires.Credit Card(Required)Card Details Cardholder Name Weekly Instalment Price: Paid Today Signature(Required) Reset signature Signature locked. Reset to sign again [/vc_column][/vc_row]
