BANK DEBIT ORDER INSTRUCTION / CREDIT CARD AUTHORITY

BANK DEBIT ORDER INSTRUCTION / CREDIT CARD AUTHORITY

HIGHWAY AQZ AQUATICS (Pty) LTD2015/135405/07

PERSONAL INFORMATION
Name Of Account Holder*

First NameLast Name
Name Of Swimmer*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Debit Amount:*
Debit Order Date*

DayMonthYear
Date on which the debit order starts and repeats each month.

ACCOUNT DETAILS
Bank*
Branch Code*
Branch Town*
Account Holders Name*
Account Number*
Account Type*

AGREEMENT
Abbreviated Shortname to be used: AQUAZONE

This signed Authority and Mandate refer to our contract as dated as on signature hereof(“the Agreement”). I / We hereby authorise you to issue and deliver payment instructions to the bank 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 the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of one full calendar notice. Cancellation on or before the 5th of the notice month will mean we will not invoice for the FOLLOWING month. If cancelled after this date, they will be charged for another month.

The individual payment instructions so authorised to be issued must be issued and delivered as follows:
On the e.g. 1st* day (“payment day”) of each and every month commencing on Date*.

In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;
Tick the appropriate box*

Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less than the obligation due;
I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. 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.

MANDATE

I / We acknowledge that all payment instructions issued by you shall be treated by my/ our above-mentioned Bank as if the instructions had been issued by me/us personally.

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.

ASSIGNMENT

I / We acknowledge that this Authority may be ceded to 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 place* on this e.g. 4th* day of month* year*
Initials and Surname*
Example of Initials and Surname: JJ Doe
Signature*

Clear
Assisted by:

Fiona CO Aquazone
Should be Empty: