ASMIRT Membership Renewal

AUSTRALIAN SOCIETY OF MEDICAL IMAGING AND RADIATION THERAPY

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Membership Number

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First Name

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Last Name

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Membership Type

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Membership Description

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Select Payment method
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Your Membership Payment Plan


Full Price: AUD$ {{ form_data['output'][form_data['pay_period']]['full_price'] | 2digit }}

Early Bird Discount: AUD$ {{ form_data['output'][form_data['pay_period']]['early_bird_discount'] | 2digit }}

Credit: AUD$ {{ form_data['output'][form_data['pay_period']]['credit'] * -1 | 2digit}}

Total: AUD$ {{ form_data['output'][form_data['pay_period']]['total'] | 2digit }}

First Payment Date: {{ form_data['output'][form_data['pay_period']]['first_payment_date'] | firstPaymentDateFilter }}

First Payment Amount: AUD$ {{ form_data['output'][form_data['pay_period']]['first_payment_amount'] }}

Subsequent Payment Amount: AUD$ {{ form_data['output'][form_data['pay_period']]['subsequent_payment_amount'] }}

Subsequent Payment Frequently: Per {{ form_data['output'][form_data['pay_period']]['subsequent_payment_freq'] }}

I agree with Terms and Conditions*
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Your membership will be covered by your credit with ASMIRT.

Please click submit to finalise the application.

Credit Card Details Credit Cards

Australian Society of Medical Imaging and Radiation Therapy (ASMIRT)

Office: Suite 1040-1044, Level 10, 1 Queens Road, Melbourne, Vic 3004 Postal: PO Box 16234, Collins Street West, VIC 8007

T: +61 3 9419 3336 | F: +61 3 9416 0783

Direct Debit Request

Request and Authority to debit

Your Surname or company nameThis field is required.

Your Given names or ABN/ARBNThis field is required.“you”

request and authorise ASMIRT (APCA ID NO. 530722) to arrange a debit to your nominated

account to pay for your membership subscription.

This debit or charge will be arranged by ASMIRT’s financial institution and made through the Bulk

Electronic Clearing System Framework (BECS) from your nominated account and will be subject to

the terms and conditions of the Direct Debit Request Service Agreement.

Amount of debit

Any amount ASMIRT, has deemed payable by you

OR

The amount specified in the invoice we have sent you, for payment on a due date

Payment Period:

Pay By:

Your account to be debited

Cardholders' NameThis field is required.

Card NumberThis field is required.

Expiry DateThis field is required.

CCVThis field is required.

Name/s on accountThis field is required.

Financial institution nameThis field is required.

BSB number (Must be 6 Digits)This field is required.Only numeric character accepted.Min length is 6.Max length is 6

Account numberThis field is required.

Your contact details

Address:This field is required.

Email:This field is required.

Phone:This field is required.

The address/email [please choose one] above is the best way for us to write to you.

Confirmation

By signing and/or providing us with a valid instruction in respect to your Direct Debit Request you confirm that:

  • you are authorised to operate the nominated account; and
  • you have understood and agreed to the terms and conditions set out in this Request and in your Direct Debit Request Service Agreement
Your Signature

Signed in accordance with the account authority on your account:

Please sign with touchscreen or mouse in the box below

Signature:
You need to sign here.

Contact details: As above

Second account signatory (if required)

Signed in accordance with the account authority on your account:

Please sign with touchscreen or mouse in the box below

Signature:

Name:

Address:

Email:

Phone:

Signing for a company

You must be authorised to sign on behalf of the company AND you must have authority to operate the Company’s bank account.

Please sign with touchscreen or mouse in the box below

Signature of duly authorised officer:

Position held:This field is required.

Name:This field is required.

Address:This field is required.

Email:This field is required.

(Notices will be sent to this email address)

Phone:This field is required.

Date:This field is required.

Second company signatory (if required)

Please sign with touchscreen or mouse in the box below

Signature of duly authorised officer:

Position held:

Name:

Email:

Date:

Australian Society of Medical Imaging and Radiation Therapy (ASMIRT)

Office: Suite 1040-1044, Level 10, 1 Queens Road, Melbourne, Vic 3004 Postal: PO Box 16234, Collins Street West, VIC 8007

T: +61 3 9419 3336 | F: +61 3 9416 0783

Direct Debit Request Service Agreement

This is your Direct Debit Service Agreement with ASMIRT (APCA ID NO. 530722 & ABN: 26924779836) (the Debit User). It explains what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit provider. Please keep this agreement for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR authorisation.
Definitions

account means the account held at your financial institution from which we are authorised to arrange for funds to be debited.

agreement means this Direct Debit Request Service Agreement between you and us.

banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia.

debit day means the day that payment by you to us is due.

debit payment means a particular transaction where a debit is made.

Direct Debit Request means the written, verbal or online request between us and you to debit funds from your account.

us or we means ASMIRT, (the Debit User) you have authorised by requesting a Direct Debit Request.

you means the customer who has authorised the Direct Debit Request.

your financial institution means the financial institution at which you hold the account you have authorised us to debit.

1. Debiting your account

1.1 By submitting a Direct Debit Request, you have authorised us to arrange for funds to be debited from your account. The Direct Debit Request and this agreement set out the terms of the arrangement between us and you.

1.2 We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request.

or

We will only arrange for funds to be debited from your account if we have sent to the address nominated by you in the Direct Debit Request, a billing advice which specifies the amount payable by you to us and when it is due.

1.3 If the debit day falls on a day that is not a banking day, we may direct your financial institution to debit your account on the following banking day. If you are unsure about which day your account has or will be debited you should ask your financial institution.

2. Amendments by us 2.1 We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice sent to the preferred email or address you have given us in the Direct Debit Request.
3. How to cancel or change direct debits

You can:

(a) cancel or suspend the Direct Debit Request; or

(b) change, stop or defer an individual debit payment at any time by giving us at least ten (10) days notice.

To do so, contact us at Postal: PO Box 16234, Collins Street West, VIC 8007 or Email: membership@asmirt.org or

by telephoning us on +61 3 9419 3336 during business hours;

You can also contact your own financial institution, which must act promptly on your instructions.

4. Your obligations

4.1 It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request.

4.2 If there are insufficient clear funds in your account to meet a debit payment:

(a) you may be charged a fee and/or interest by your financial institution;

(b) we may charge you reasonable costs incurred by us on account of there being insufficient funds; and

(c) you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment.

4.3 You should check your account statement to verify that the amounts debited from your account are correct.

5 Dispute

5.1 If you believe that there has been an error in debiting your account, you should notify us directly on Postal: PO Box 16234, Collins Street West, VIC 8007 or Email: membership@asmirt.org Alternatively you can contact your financial institution for assistance.

5.2 If we conclude as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging within a reasonable period for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted.

5.3 If we conclude as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing.

6. Accounts

You should check:

(a) with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions.

(b) your account details which you have provided to us are correct by checking them against a recent account statement; and

(c) with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request.

7. Confidentiality

7.1 We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.

7.2 We will only disclose information that we have about you:

(a) to the extent specifically required by law; or

(b) for the purposes of this agreement (including disclosing information in connection with any query or claim).

8. Contacting each other

8.1 If you wish to notify us in writing about anything relating to this agreement, you should write to

ASMIRT Postal: PO Box 16234, Collins Street West, VIC 8007 or Email: membership@asmirt.org

8.2 We will notify you by sending a notice to the preferred address or email you have given us in the Direct Debit Request.

8.3 Any notice will be deemed to have been received on the second banking day after sending.