ORDER FORM 2015 www.hamperking.com.au Please complete the form in CAPITALS using BLACK OR BLUE PEN 1. Membership Details 3. Delivery Address/Gift Order Address I am a new member I am an existing member Membership Number Go straight to Section 6 Unit/Flat No. Street No. 2. Mailing Address If your mailing address is a PO Box, please complete Delivery Address section Mrs Use this only if your delivery address is different to your mailing address and cannot be a PO Box address Ms Miss Mr Street Name Dr First Name Suburb Last Name State Date of Birth ⁄ ⁄ Postcode 4. Agent Details Unit/Flat No. First Name Street No. Last Name Street Name Agent No. 5. Payment Details Please debit my account as follows Suburb State Date for payments to start Postcode ∕∕ Please use your next pay date so we can work out when to Debit your account if applicable. Tel (Mobile) Weekly (W) Fortnightly (F) Monthly (M) Tel (Other) Week Day (Mon – Fri, first 3 letters) Email All Direct Debits are deducted on the evening of the day nominated We’ll confirm your payment start date & amount via mail or email 6. Direct Debit Request (please tick if using this option) I already have a Direct Debit with Hamper King & I haven’t cancelled it so I don’t need to fill out the form below (go to Section 7) OR complete the section below Customer’s Authority I/We (First & last name of customer(s) giving Direct Debit Request) authorise and request LAYBY SERVICES AUSTRALIA PTY LTD 375626 to arrange for funds to be debited from my/our account at the financial institution identified above and as prescribed below through the Bulk Clearing System (BECS). This authorisation is to remain in force in accordance with the terms described in the service agreement, which I have read and understood. Your direct debit will show that payment is made to Hamper King. Details of the account to be debited (all details must be supplied, as they appear on your bank account) Name of Financial Institution Branch Name Account Name BSB Number – Account Number 7. Confirmation Details I am 18 years or over and acknowledge the agent details on this form will remain unchanged for the rest of this payment year (where applicable). I have read and accept the terms & conditions in the 2015 Hamper King Big Book or online at www.hamperking.com.au When you order is fully paid, we’ll keep your payments going so you can keep saving for next year’s order. You can choose not to have this option by ticking here. Signature 1 Date Signature 2 Date ∕ ∕ ∕∕ You can mail, fax or complete your order online. Local Call: 1300 305 300 Fax: (02) 9008 4699 Mail: PO Box 7190, Alexandria NSW 2015 8. Cheque / Money Order Payment (please tick if using this option) 9. Order Details Mid Year Plan CODE Christmas Plan Code ✔ 1 0 0 1 Product Name Hamper Name KING S H AM P E R EX AM PLE ON Hamper Price Qty LY TOTAL PRICE 0 1 $ 1 4 5 2 $ 1 4 5 2 Personalised Details (please insert the name in the boxes below) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ QTY Total Price $ 2 2 0 8 Personalised Name Necklace 1 1 8 5 My Birthday Teddy Line 1 If you would like to order more than one personalised item, please call 1300 305 300 to inform us of your personalisation details. Line 2 $ Line 3 Add up total order value $ Place your order online to SAVE $25* INSTANTLY! www.hamperking.com.au Minumum $500 Total Order. Excludes Gift Cards.