ADSL/Hosting Subscription

Company
Name:
Trading
Name:
Registration/
ID No:
Postal
Address:
Telephone
No:
  Fax No:
  Contact
Person:
  Authorised
Signature:
ADSL
Packages:
(Not required if it's just hosting)
Hosting
Packages:
   
Domain:    
Domain Name: Option1:
(If New) Option2:
  Option3:
Email:
DEBIT ORDER INSTRUCTION
Bank Details:
Account Name:
Bank Name:
Branch Name:
Branch Code:
Account Number:
Type of Account:
We hereby “instruct and “ authorise you to draw against my/our account with the abovementioned bank (or any other bank or branch to which I/we transfer my/our account) the sum of R , “the amount necessary for payment of the monthly instalment due in respect of abovementioned agreement on the second last working day of each and every month commencing on and continuing until termination of our agreement or until cancelled by me/us in writing. All such withdrawals from my/our bank by you shall be treated as though they had been signed by me/us personally.

I/we understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher.

I/we agree to pay any bank charges relating to this debit order instruction.

This authority may be cancelled by me/us by giving you thirty days’ notice in writing, sent by prepaid registered post, but I/we understand that I/we shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

Receipt of this instruction by you shall be regarded as receipt thereof by my/our bank.

 
Verification:
 
 
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