"*" indicates required fields Please complete the below form to submit your request. Member DetailsMember Number* Member Name* Address* Street Address Address Line 2 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.SignaturePerson 1SignaturePerson 2Payment Type Bank Account Credit Card BSB* Account No* Name on Account* Card No* Expiry Date* Name on card* Please upload all relevant attachmentsFileMax. file size: 32 MB.EmailThis field is for validation purposes and should be left unchanged.