YOUR SUCCESS EXCLUSIVE OFFER
ACCEPTANCE FORM (A tax invoice upon payment) PACKAGE INCLUSION
Value
Via Express
Via Instalments
Your Success Program – Your 12 Keys to Extraordinary Living
$3000
Your Success Exclusive Event –
$2000
BONUS
BONUS
Your Success Club Annual Membership Fee
$197
BONUS
BONUS
$5197
$5197
YOUR TOTAL VALUE
YOUR INVESTMENT YOUR TOTAL SAVING
$3191
$997
$2006
$3200
STEP 1 – YOUR DETAILS
STEP 3 – PAYMENT INFORMATION
Please fill in all the below fields
Please select ONE of the options below:
Given Names:
Surname:
$5197
$1508 ($29 per week) $3689
CREDIT CARD / DEBIT CARD, OR
I request you The Coaching Institute to arrange for funds to be debited from my nominated credit card according to the schedule specified above and attached Direct Debit Service Agreement.
Street Address: Suburb: State:
Postcode:
Card Type:
Phone Number:
Card No.
Email Address:
Expiry Date:
Date of Birth:
Cardholder Name:
Driver License #
Signature
STEP 2 – INVESTMENT AMOUNTS
Visa MasterCard BankCard AMEX*
CHEQUE / SAVINGS ACCOUNT, OR
Date:
I request & authorise The Coaching Institute (314011) to arrange, through its own financial institution, a debit to my nominated account any amount The Coaching Institute (314011), has deemed payable by me. This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the terms & conditions of the Direct Debit Request Service Agreement.
VIA INSTALMENTS Deposit Amount: AUD$
Bank Name:
Payment Date :
BSB Number:
Please select ONE of the options below:
VIA EXPRESS Investment Amount:
AUD$997
Ongoing Amount:
AUD$
Frequency:
Weekly Fortnightly Monthly
Commencement Date: Total to Collect:
Account Name: Account Number:
DIRECT DEPOSIT (DEPOSIT & FULL PAYMENTS ONLY), OR
Payable to The Coaching Institute at the following account
AUD$1497
Bank Name:
Westpac
Account Name:
The Global Success Institute Pty Ltd
BSB Number:
033 126
Account Number:
509 858
CASH / CHEQUE (DEPOSIT & FULL PAYMENTS ONLY)
Payable to The Coaching Institute *Surcharge applies: American Express 1.8%
TERMS & CONDITIONS
I have read and accepted The Coaching Institute’s Terms and Conditions of Purchase (on the reverse)
Signature:
I have read and accepted the Direct Debit Request Service Agreement
Date:
ABN 21 163 412 057 | GSI F 102 (C) ACCEPTANCE FORM – YOUR SUCCESS EXCLUSIVE OFFER | V6 | 06 Mar 2017 Page 1 of 3 Suite 40, 37-39 Albert Rd, Melbourne | VIC 3004 | Australia | Tel (+61) 3 9645 9945 | Fax +613 9645 7002 | info@thecoachinginstitute.com.au | www.thecoachinginstitute.com.au