Direct Debit Request

Email Address:
First Name:
Last Name:
Mobile Phone:
Address:
Suburb:
State:
Postcode:

Payments To:
KBOD Fitness
PO BOX 522

Miami, Queensland, 4220
hello@kbodfitness.com

Item summary

Item DescriptionUnit PriceQuantityDiscountTaxTotal
UNLIMITED WEEKLY MEMBERSHIP$45.001$0.00$45.00

Debit Summary

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**A merchant handling fee applies**
BusKey
DevKey
eDebitNumber
ClientReference
FirstName
LastName
Address
City
State
Postcode
Tel
Email
InitialFee
DebitDate
DebitAmt
Frequency
UFN
DebitCount
DebitFee
CreditCardFee
Description
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