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Application for membership – Bank account 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 – fortnightly direct debit from bank account
   
 Bank name
 Branch
 Account name(s)
 BSB
 Account number
   
 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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