Forms Direct Debit "*" indicates required fields Please complete the below form to submit your request.Member DetailsMember Number*Member Name*Address* Address* City* State* Postcode* I / we request Cessnock District Health Benefits Fund Dr - 088892 to arrange for funds to be Debited from my nominated financial institution shown below. Please note: Joint Accounts require both signatures.Signature*Person 1SignaturePerson 2Payment Type Bank Account Credit Card BSB*Account No*Name on Account*Card No*Expiry Date*Name on card*Please upload all relevant attachments Drop files here or Select files Max. file size: 32 MB. CommentsThis field is for validation purposes and should be left unchanged.
