Client Details Name * Reference Number * Quoted Charges Acceptance of Offer * I/We confirm that I/we have received and agree to the Conditions of Contract for Removal and Storage. Storage Per Month * $ Payment I/We agree that storage and related charges are payable on the 20th of each month by the following payment method * Direct Debit from my Authorised Bank Account Direct Debit from my Authorised Visa/MasterCard (surcharge of 2.0% applicable) Direct Debit Authorisation Authorisation_Account * I/We request and authorise CONROY REMOVALS PTY LTD (407130) to arrange, through its own financial institution, a debit to your nominated account any amount CONROY REMOVALS PTY LTD (407130), has deemed payable by you. This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement. Financial Institution * Branch * Account Name * Account Number * BSB * View the Terms and Conditions of Direct Debit. Authorise Acknowledgement * I/We request and authorise Acknowledement. By ticking you provide 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 CONROY REMOVALS PTY LTD as set out in this Request and in your Direct Debit Request Service Agreement. I/We authorise Conroy Removals, until further notice in writing, to debit my/our Visa/MasterCard with all amounts payable. Requirements Place of Storage * - Select -BrisbaneMelbournePerthSydneyTownsvilleBrisbane SouthDarwin Period of Storage * -Select-0-1 month1-3 month3-6 month6 month + Contact Details While my Goods are in Storage Address Phone Email * Persons to Act on Behalf (if applicable) I/We authorise the following person I/We authorise the following nominated person to act as my/our agent with my/our complete authority to deal with the goods including acceptance of delivery, change of address or storage inspections during my/our absence. Name * Address * Phone * Email * Inventory of Goods Copy of Inventory * I/We understand that I/we will receive a copy of the Inventory of my/our effects, compiled on pick up duly endorsed by me/us and the representative of Conroy Removals on site. I/We understand that this will constitute receipt of my/our effects into storage. Removal From Storage Removal From Storage * I/We agree to provide at least one weeks notice in writing of the intention to have my/our goods removed from storage, and payment of all due charges.