PharmOutcomes Direct Debit Agreement

Member Number*

If you are part of a group and wish to be invoiced at head office level, please complete the form using your head office member number. If you wish to be invoiced at branch level please complete the form multiple times, once for each of your branches

Pharmacy Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone Number*

Bank Sort Code*

Bank Account Number*

Name on Bank Account*

Direct Debit Guarantee*

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.

If there are any changes to the amount, date or frequency of your Direct Debit National Pharmacy Association Ltd will notify you 3 working days in advance of your account being debited or as otherwise agreed. If you request National Pharmacy Association Ltd to collect a payment, confirmation of the amount and date will be given to you at the time of the request.

If an error is made in the payment of your Direct Debit, by National Pharmacy Association Ltd or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society – if you receive a refund you are not entitled to, you must pay it back when National Pharmacy Association Ltd asks you to.

You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

I accept the Direct Debit Guarantee

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.