Xtend Application Form

Xtend Fibre Application Form
Full name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternative contact number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
ID/Passport Number*
ID/Passport*

Cancelof
Proof Of Banking*

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
20/5 Mbps Month-to-Month R 44030/30 Mbps Month-to-Month R 59060/60 Mbps Month-to-Month R 775100/100 Mbps Month-to-Month R 890200/200 Mbps Month-to-Month R 999
Special Instructions: (If applicable)
Debit OrderEFT

NetX Fibre

Debit Order Mandate
NetX Tech (Pty) Ltd

Registration number: 2021/532248/07

Email Address: accounts@netxtech.co.za

Milestone Place Block A Unit 4

25 Sovereign Road Route 21 Office Park Gauteng 0157
Netx Tech (Pty) Ltd
A. Authority/Mandate: Paper/Electronic
Given by (name of Accountholder):*

First NameLast Name
Bank Account Detail
Bank Name:*
Branch Name and Town:*
Branch Number:*
Account Number:*
Type of Account:*
Date:*

MonthDayYear
Date
Contact Number:*
Amount:*
I/We hereby authorise Netcash (Pty) Ltd to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our above mentioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference Number.

The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement.

The payment instructions so authorised to be issued must carry the Contract Reference Number, included in the said payment instructions, and must be provided to identify the specific contract. The said Contract Reference Number should be added to this form in section E before the issuing of any payment instruction and communicated directly after having been completed.
I /we agree that the first payment instruction will be issued and delivered on 1st 16th 26th (date) and thereafter regularly on the 1st 16th 26th of each month.
If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or

Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above.

B. MANDATE

I/we acknowledge that all payment instructions issued by you will be treated by my/our abovementioned bank as if the instructions had 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 also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate 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.
Signed* on this * day of *
SIGNATURE AS USED FOR OPERATING ON THE ACCOUNT*

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Xtend banking details:

Our banking details:
NetX Tech (Pty) Ltd

Bank name: First National Bank

Account number: 63098331803

Branch code: 210554

Branch name: Commercial Account Services

Reference: Invoice number
Signature*

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Xtend Fibre Application Form

NetX Fibre

Bank Account Detail