Once you complete this form your credit card will be debited today. It will then be debited on the first day of every draw (held quarterly).
By completing this form and providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to the terms and conditions governing the debit arrangements between you and Muscular Dystrophy Queensland Limited. as set out in this Request and in your Direct Debit Request Service Agreement.
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Authorisation Form