Victorian Ambulance Union

Online Application Form

1) Personal Details 2) Membership Type 3) Direct Debit Details 4) Declaration & Submit 5) Finish

My Details

Title*

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First Name *

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Middle Name

Family Name *

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Preferred Name

Preferred Pronouns

Date of Birth * (DD/MM/YYYY)

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Gender

My Contact Details

Primary Email Address * (this should not be your work address)

Primary Email has already been used

Alternate Email Address

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Primary Mobile Number *
(It must start with 0 and must be 10-digit long with no spaces.)

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Alternate Number (if a landline, enter the area code and follow with the phone number. It must start with 0 and must be 10-digit long with no spaces.)

My Home

Address line 1 *

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Address line 2

Suburb *

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State *

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Postcode *

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Are you applying for student membership? (not currently employed in the industry)

My Employment Details

Occupation *
(select 'Other' if not listed)

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Employee Number *

Please enter Other Profession

Employment Type *

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Primary Employer * (select 'Other' if not listed)

Primary Workplace

Employer 1 (select 'Other' if not listed)

Workplace

Employer 2 (select 'Other' if not listed)

Workplace

Employer 3 (select 'Other' if not listed)

Workplace

Address line 1 *

Address line 2

Suburb *

State *

Post code *

Other Details

How did you hear about the VAU? *
(select 'Other' if not listed)

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Select delegate from the list.
(select 'Other' if not listed)

Required

Membership Type

Select Membership Type

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Payment Frequency

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Direct Debit Request - Payment Method

Directly debit the membership fee from

Bank Account

Credit Card Account

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BSB Number

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Account Number

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Account Name

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I/We hereby Ezidebit Pty Ltd ACN 096 902 813 (User ID 165969) to debit my/our account at the Financial institution identified above through the Bulk Electric Clearing System (BECS) in accordance with the Debit Arrangement stated above and this Direct Debit Request and as per the EziDebit Service Agreement (Ver 1.11) provided.

Credit Card Type

Visa

Mastercard

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Cardholder Name

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Card Number

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Expiry Date (MM/YYYY)

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CVV

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Review Your Application

You are about to submit the following details:

My Details

Title

##title##

First Name

##firstname##

Middle Name

##middlename##

Family Name

##lastname##

Preferred Name

##preferredname##

Preferred Pronouns

##pronoundescription##

Date of Birth

##dob##

Gender

##gender## , ##genderdesc##

I am applying for student membership.

##applyforstudent##

Occupation

##profession##

If other occupation, please specify.

##other_profession##

I am studying the paramedic degree. (this is answered by ambulance attendant or patient transport offcier only)

##studyparamedic##

Employee number

##employeenumber##

Employment Type

##employmenttype##

My Primary Contact Details

Primary Email Address

##primary_email_address##

Alternate Email Address

##alternate_email_address##

Primary Mobile Number

##primary_mobile_number##

Alternate Number

##alternate_number##

My Home

Address

##home_address1## ##home_address2##
##home_suburb## ##home_state##
##home_postcode##

My Work

Primary Employer

##primary_employer##

Primary Workplace

##primary_workplace##

Primary Employer - Employer/Company Name, Workplace Name

##other_employer##

Other Employer 1

##other_employer1##

Other Workplace 1

##other_workplace1##

Other Employer 1 - Employer/Company Name, Workplace Name

##other1_employer_other##

Other Employer 2

##other_employer2##

Other Workplace 2

##other_workplace2##

Other Employer 2 - Employer/Company Name, Workplace Name

##other2_employer_other##

Other Employer 3

##other_employer3##

Other Workplace 3

##other_workplace3##

Other Employer 3 - Employer/Company Name, Workplace Name

##other3_employer_other##

Address Details (required if other)

##other_workplace_address1## ##other_workplace_address2##
##other_workplace_suburb## ##other_workplace_state##
##other_workplace_postcode##

How did you hear about the VAU?

##heardabout##

Membershp Type

Membership Type

##membership_type##

Payment Frequency

##payment_freq##

Your Regular Debit Amount

$##debit_amount##

ECD Employment Start Date

##ecdEmploymentStartDate##

Employment Evident Document

##ecdFileUpload##

Payment Schedule

##ecdPaymentSchedule##

Direct Debit Request - Payment Method

Bank Details

Name: ##account_name##
BSB: ##bsb##
Bank Account Number: ##account_number##

Credit Card Details

Name: ##cardholder_name##
Card Type: ##credit_card_type##
Card Number: ##credit_card_number##
Expiry: ##expiry_date##
CVV: ##cvv##

Service Level Agreement From Ezidebit

Global Payments Australia 1 Pty Ltd ACN 601 396 543 I Authorised Representative under AFSL 315388

Ezidebit DDR Service Level Agreement (Ver 1.11)

I/We hereby authorise Global Payments Australia 1 Pty Ltd ACN 601 396 543 (Direct Debit User ID number 342190, 342191, 428198) (referred to as "Ezidebit'1 to make periodic debits on behalf of the Business (referred to as "the Business") as indicated on the attached Direct Debit Request which incorporates this DDR Service Agreement.

I/We acknowledge that Ezidebit is acting as a Direct Debit Agent for the Business and that Ezidebit does not provide any goods or services (other than the direct debit collection services) to me/us for the Business pursuant to the Direct Debit Request and has no express or implied liability in relation to the goods and services provided or to be provided by the Business or the terms and conditions of any agreement that I/We have with the Business.

I/We acknowledge that the debit amount will be debited from my/our nominated card or bank account according to the terms and conditions of my/our agreement with the Business and the terms and conditions of the Direct Debit Request (and specifically the Debit Arrangement including the Fees/Charges in the Direct Debit Request).

I/We acknowledge that the details of my/our nominated card or bank account should be verified (eg: against a recent card or bank statement) to ensure accuracy of the details provided and I/we will contact my/our financial institution if uncertain of the accuracy of these details.

I/We acknowledge that is my/our responsibility to ensure that there are sufficient available/cleared funds in the nominated account by the due date to enable the direct debit to be honoured on the due date for the debit. Direct debits normally occur overnight, however transactions can take up to 3 banking business days depending on the financial institution. Accordingly, I/we acknowledge and agree that sufficient funds will remain in the nominated account until the debit amount has been debited from the account. If there are insufficient funds available, I/we agree that Ezidebit will not be responsible for any fees and charges that may be charged by either my/our or its financial institution.

I/We acknowledge that there may be a delay in processing the debit if:

1. A payment request is received by Ezidebit after Ezidebit's usual cut off time, being 3:00pm Qld time, Monday to Friday;
2. A payment request is received by Ezidebit on a day that is not a banking business day in Sydney, NSW and Melbourne, VIC; or
3. There is a public or bank holiday on the day when the debit transaction is due to be processed or on any of the following days until the debit is processed. Any payment that falls due on any of the above will be processed on the next business day.

I/We authorise Ezidebit to vary the amount of the payments from time to time upon receiving instructions from the Business of a variation provided for within my/our agreement with the Business or as may be agreed by me/us and the Business. I/We do not require Ezidebit to notify me/us of the variation to the debit amount.

I/We acknowledge that Ezidebit is to provide at least 14 days' notice if it proposes to vary any of the terms and conditions of the Direct Debit Request (including this DDR Service Agreement) including varying the Debit Arrangement.
I/We will contact the Business if I/we wish to alter or defer the Debit Arrangement.
I/We acknowledge that any request by me/us to stop or cancel the Debit Arrangement will be directed to the Business.

I/We acknowledge that any dispute regarding a debit will be directed to the Business and/or Ezidebit. If no resolution is forthcoming, I/we will contact my/our financial institution.
I/We acknowledge that if a debit is returned by my/our financial institution as unpaid, a failed payment fee (as referred to in the Debit Arrangement) may be payable by me/ us to Ezidebit. I/We will also be responsible for any fees and charges applied by my/our financial institution for each unsuccessful debit attempt together with any collection fees, including but not limited to any solicitor fees and/or collection agent fee as may be incurred by Ezidebit.

I/We authorise Ezidebit to attempt to re-process any unsuccessful payments as advised by the Business.

I/We acknowledge that certain fees and charges (including setup, variation, SMS or processing fees) may apply to the Direct Debit Request and may be payable to Ezidebit and agree to pay those fees and charges to Ezidebit.

"Ezidebit" may appear as the merchant for a payment from my/our credit card (including a debit or charge card). I/We acknowledge and agree that Ezidebit will not be liable for any disputed transactions resulting from the supply or non supply of goods and/or services and that all disputes will be directed to the Business (as Ezidebit is acting only as a Direct Debit Agent for the Business). The Transaction Fee for a debit to a Credit Card calculated as a percentage may be subject to a minimum amount.

I/We appoint Ezidebit as my/our agent for the control, management and protection of my/our personal information (relating to the Business and this Direct Debit Request) which is disclosed to Ezidebit. I/We irrevocably authorise Ezidebit to take all necessary action (which Ezidebit deems necessary) to protect and/or correct, if required, my/our personal information, including (but not limited to) correcting account numbers and providing such information to relevant third parties and otherwise disclosing or allowing access to my/our personal information to third parties in accordance with the Ezidebit Privacy Policy.

Other than as provided in this Direct Debit Request or the Ezidebit Privacy Policy, Ezidebit will keep your personal information about your nominated account private and confidential unless this information is required to investigate a claim made relating to an alleged incorrect or wrongful debit, to be referred to a debt collection agency for the purposes of debt collection or as otherwise required or permitted by law. The Ezidebit Privacy Policy can be found at http://www.ezidebit.com.au/privacy-policy/

I/We hereby irrevocably authorise, direct and instruct any third party who holds/stores my/our personal information (relating to the Business and this Direct Debit Request) to release and provide such information to Ezidebit.

I/We authorise:

1. Ezidebit to verify with my/our financial institution and/or correct, if necessary, details of my/our account; and
2. My/our financial institution to release information allowing Ezidebit to verify my/our account details.

I agree to the Terms and Conditions from Ezidebit.

Service Level Agreement From Payment Express

Direct Debit Request Service Agreement

VAU

About

This is your Direct Debit Service Agreement with the Victorian Health Professionals Association (VAHPA) ABN 38 106 461 384 (formerly the HSU Health Professionals Vic No. 3 Branch). It explains what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit provider.
Please keep this agreement for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR authorisation.

Definitions

account means the account held at your financial institution from which we are authorised to arrange for funds to be debited.

agreement means this Direct Debit Request Service Agreement between you and us.

banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia.

debit day means the day that payment by you to us is due.

debit payment means a particular transaction where a debit is made.

direct debit request means the Direct Debit Request between us and you.

us or we means Victorian Allied Health Professionals Association (VAHPA), (the Debit User) you have authorised by requesting a Direct Debit Request.

you means the customer who has signed or authorised by other means the Direct Debit Request.

your financial institution means the financial institution nominated by you on the DDR at which the account is maintained.

1. Debiting your account

1.1 By signing a Direct Debit Request or by providing us with a valid instruction, you have authorised us to arrange for funds to be debited from your account. You should refer to the Direct Debit Request and this agreement for the terms of the arrangement between us and you.

1.2 We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request.

2. Amendments by us

2.1 We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice.

3. Amendments by you

You may change, stop or defer a debit payment, or terminate this agreement by providing us with at least fourteen (14) days notification by writing to:

Victorian Allied Health Professionals Association
PO Box 13286, Law Courts, Vic 8010
or
by telephoning us on 1300 322 917 during business hours;
or
arranging it through your own financial institution, which is required to act promptly on your instructions.

4. Your obligations

4.1 It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request.

4.2 If there are insufficient clear funds in your account to meet a debit payment:
(a) you may be charged a fee and/or interest by your financial institution;
(b) you may also incur fees or charges imposed or incurred by us; and
(c) you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment.

4.3 You should check your account statement to verify that the amounts debited from your account are correct

5. Dispute

5.1 If you believe that there has been an error in debiting your account, you should notify us directly on 1300 322 917 and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up directly with your financial institution.

5.2 If we conclude as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted.

5.3 If we conclude as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing.

6. Accounts

You should check:
(a) with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions.
(b) your account details which you have provided to us are correct by checking them against a recent account statement; and
(c) with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request.

7. Confidentiality

7.1 We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.

7.2 We will only disclose information that we have about you:
(a) to the extent specifically required by law; or
(b) for the purposes of this agreement (including disclosing information in connection with any query or claim).

8. Notice

8.1 If you wish to notify us in writing about anything relating to this agreement, you should write to
Victorian Allied Health Professionals Association
PO Box 13286, Law Courts, Vic 8010

8.2 We will notify you by sending a notice in the ordinary post to the address you have given us in the Direct Debit Request.

8.3 Any notice will be deemed to have been received on the third banking day after posting.

I agree to the Terms and Conditions from Payment Express.