Please Print and Fax to 0883639422 0r post to Q Life Pty Ltd

suite 4, 6-8 Dequetteville Tce, Kent Town SA 5067

Direct Credit Authorisation Form

Payment plan

ᆷVisa ᆷMastercard

I _____________________, authorise Q Life Pty Ltd to directly

debit $895 from my credit card account and $260.50 every fortnight for 10

fortnights commencing as of 31/01/08. I understand that this is a

contract and I agree that I am committing to the contract.

Signature: ________________________________

Pay in full

ᆷVisa ᆷMastercard ᆷCheque (Payable to Q Life Pty Ltd)

I _____________________, authorise Q Life Pty Ltd to directly

debit $3150 from my credit card.

Signature: ________________________________

Credit card number: ____________________________________

Expiry Date: __/__

Name on card: ____________________________________

Signature: __________________________________