S235851 · OPW21/0118

 Declaration

            •   I certify that the information provided is true, correct and complete to the best of my knowledge and belief, knowing it is an offence to
                provide false or misleading information.*


            •   I agree that this declaration is to be used within the meaning of the Electronics Transactions (Queensland) Act 2001 as an electronic
                communication containing my signature for the purpose of that Act.*



Amount due

  $16,719


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EFT/Invoice *

     EFT

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Do you require confirmation of notification and payment once QLeave has received your payment? *

    Yes                                                                             No


EFT

Upon submission an e-mail will be sent to [email protected] with QLeave’s bank account details for the electronic funds transfer.

Once QLeave receives your payment, a confirmation of payment will be emailed to the contact person listed on this form:
[email protected]



QLeave banking details -

Bank: Commonwealth Bank of Australia
Account Name: QLeave
BSB: 064-013
Account Number: 10006042
Reference: S235851