Hockey NSW State Teams - Payment Plan

This form is to be completed by the player (or parent of a player) requesting a Payment Plan with Hockey New South Wales and returned to Hockey New South Wales prior to Tax Invoice payment due date.

Full payment for State Team Representation needs to be made prior to the National Championships to ensure team representation.

Please note, if a Payment Plan is approved and installment payments are missed, Hockey NSW won’t be able to offer future payment arrangements

PAYMENT PLAN REQUEST

Application Requested by:*

ATHLETE DETAILS

Full Name*

DOB*

YYYY/MM/DD

Contact Email*

Contact Number*

Address*

Street #, Street Name, Suburb, State and Postcode

Association

PARENT/GUARDIAN DETAILS

Address (if different to athlete)

Street #, Street Name, Suburb, State and Postcode

Parent/Guardian Full Name

Parent/Guardian Email Address

Parent/Guardian Contact Number

TEAM DETAILS

Which state teams does this application refer to?*

Indoor or Field*

PAYMENT PLAN SETUP

I apply to pay an initial amount of $____*

I would like to pay the remaining balance over ______*

Weekly Installments (Max. 8)

Fortnightly Installments (Max. 4)

Team Levy Total*

CONTRACT AND AGREEMENT

I agree that the total of my player levy needs to be paid prior to the commencement of the campaign I am a part of. Failure to pay this amount may sacrifice my position on the NSW State Team*

Signed By Full Name

Parent/Guardian if Under 18