| Name
(Debtor) |
_____________________________ |
Date : |
______________________ |
| Address
: |
_____________________________
_____________________________ |
Account
No as per statement received from Vanslife.com: |
______________________ |
| |
_____________________________ |
|
|
| |
_____________________________ |
|
Dear Sirs/Madams |
|
The details of my/our
account are as follows: |
| BANK : |
_____________________________ |
|
|
| BRANCH
TOWN : |
_____________________________ |
|
|
| BRANCH
NO: |
_____________________________ |
|
|
| ACCOUNT
NAME. : |
_____________________________
_____________________________ |
|
|
| ACCOUNT
NO. |
_____________________________ |
|
|
| TYPE OF
A/C : |
_____________________________ |
|
(Savings, Current,
Transmission) |
| |
|
|
|
|
I/we hereby request and authorize you to
draw against my/our account with the abovementioned bank (or any other
bank or branch to which I/we may transfer my/our account) the sum of
| AMOUNT: |
R______________________
|
| AMOUNT IN WORDS:_______________________________________________________ |
|
or any variable amount pertaining to this agreement,
on the last working day of each month.
This being the amount necessary for the settlement of the monthly or
once of amount due to you in respect of Domain Name Registration,
Website Hosting, Designing, Maintenance, Internet Access Services or any
other services
as per monthly account submitted to me/us on the last
Friday of each month. |
|
All such withdrawals from my/our account by
you shall be treated as though they had been signed by me/us personally. |
|
I/we the undersigned, "instruct" and
authorize your agent Netcash (Pty) Ltd, to draw against my/our account.
I/we understand that if bank details have been supplied the withdrawals
authorized here will be processed by BankServ. I/we also understand that
details of each withdrawal will be printed on my/our statement. |
|
I/we agree to pay any banking charges
relating to this debit order instruction. |
|
This authority may be cancelled by means of
giving you thirty days notice in writing, sent by prepaid registered
post. I/we understand that I/we shall not be entitled to any refund
of amounts, which you have withdrawn whilst this authority was in force
if such amounts were legally owing to you. |
|
Assignment: |
|
I/We acknowledge that the party hereby
authorized to effect the drawing(s) against my/our account may not cede
or assign any of its rights and that I/we may not delegate any of my/our
obligations in terms of this contract/authority to any third party
without prior written consent of the authorized party. |
|
Signed at _________________ on this
_________________ day of _________________ 20__ |
|
SIGNATURE AS USED FOR
SIGNING MY/OUR CHEQUES ON THE LINE BELOW:
|
___________________________________________________ |
|
|
Please Note:
Reconnection fees payable for failed Debit Order transaction: R75.00 |
|
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