Pilot survey payment form

Thank you for completing the pilot survey and participating in the feedback session, fill out the form below to be paid.

Don't forget to date and sign!

1. Preferred Name(Required)

2. I am claiming this payment of $50 for completion of the pilot survey and participation in the feedback session.(Required)

To be paid by PayID (mobile provided)

To be paid by direct debit (BSB + Account number provided)

3. For direct debit please provide your BSB and Bank Account number:

Please double check and re-enter your BSB and Bank Account number:

4. For PayID please provide your mobile number:

5. Your email address:(Required)

You will receive a confirmation email when you have submitted this payment form.

Signature(Required)

Date(Required)