Application for membership – Credit card direct debit

Please complete your details below
Employer number
Date of birth
Gender
Salutation
First name
Middle name
Surname
Home address
Postcode
Home phone
Mobile
Email address
Repeat email
Employer
Designation
Workplace
Team / Department
Work address
Work postcode
Work phone
Work fax
Hours worked per week
Are you
Shift
Are you interested in becoming a
workplace rep or contact?
Account information – Direct debit from credit card
Deduction frequency
Card type
Card number
Expiry date
Application agreement
Direct Debit Customer Authority
I have read, understood and agree with
the above Application Agreement and
Direct Debit Customer Authority and
wish to make application to become a
member of the CEPU
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