Client Details Name * Reference Number * Quoted Charges Acceptance of Offer * I/We confirm that I/we have read and agree to the Conditions of Storage. Storage Per Month * $ Payment I/We agree that storage and related charges are payable on the 25th of each month by the following payment method * Direct Debit from my Authorised Bank Account Direct Debit from my Authorised Visa/Mastercard (surcharge of 2.5% applicable) Direct Debit Authorisation Bank * Branch * Account Name * Account Number * If your suffix has only 2 digits please insert a zero before Conroy Removals Authorization Code - 0220768 View the Terms and Conditions of Direct Debit. authorization_account * I/We authorise you, until further notice in writing, to debit my/our account with all amounts which Conroy Removals (the initiator), the registered initiator of the above Authorisation Code, may initiate by Direct Debit. I/We acknowledge and accept that the bank accepts this authority only upon the terms and conditions listed above. I/We authorise Conroy Removals, until further notice in writing, to debit my/our Visa/MasterCard with all amounts payable. Requirements Place of Storage * - Select -Conroy Removals AucklandConroy Removals ChristchurchConroy Removals NapierConroy Removals NelsonConroy Removals New PlymouthConroy Removals TaurangaConroy Removals WellingtonConroy Removals Dunedin Period of Storage * -Select-0-1 month1-3 month3-6 month6 month + Contact Details While my Goods are in Storage Address Phone Email * Persons to Act on Behalf (if applicable) I/We authorise the following person I/We authorise the following nominated person to act as my/our agent with my/our complete authority to deal with the goods including acceptance of delivery, change of address or storage inspections during my/our absence. Name * Address * Phone * Email * Inventory of Goods Copy of Inventory * I/We understand that I/we will receive a copy of the Inventory of my/our effects, compiled on pick up duly endorsed by me/us and the representative of Conroy Removals on site. I/We understand that this will constitute receipt of my/our effects into storage. Removal From Storage Removal From Storage * I/We agree to provide at least one weeks notice in writing of the intention to have my/our goods removed from storage, and payment of all due charges. Submit