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Debit Order Authority
Your Name
Contact Telephone Number
Mobile
Email
Company Name
Your Bank Name
Account Number
Branch Number
Type of Account
Cheque
Savings
Transmission
Amount to be Deducted
Start Date
To (name of beneficiary) / Abbreviated Name - Payments Connect
Beneficiary’s Address - 1 Erica Avenue, Westridge, Somerset West, 7130
This signed Authority and Mandate refers to our contract dated
The Agreement Date Signed
I/We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my/our above-mentioned account at my/our above-mentioned Bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement and commencing on:
Commencement Date
In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day. Payment Instructions due in December may be debited against my account on the last day of the month. I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I also understand that details of each withdrawal will be printed on my bank statement. Such must contain a number, which must be included in the said payment instruction and if provided to me should enable me to identify the Agreement. This number must be added to this form in Section E before the issuing of any payment instruction.
B. Mandate
I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned Bank as if the instructions have been issued by me/us personally.
C. Cancellation
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force if such amounts were legally owing to you.
D. Assignment
I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
Signed at
Signed on
Full Name and Surname
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