Imali Imali Debit Order Form

Payment option*

Debit OrderBy Card
Client Name & Surname*
Type of Identification*

RSA ID DocumentPassport
ID Number*
Date of birth*
Passport Number
Phone Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province*
I understand and accept that there is a waiting period*

I accept
By signing and submitting this form, you acknowledge that you have read, understood and accept the Terms and Conditions of Imali Imali Coupon Program.
Imali Imali Coupon Program*

I understand my monthly debit will be R135 per month
My Products*
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Imali Imali Coupon ProgramSign up for just R135/month and receive a R5000 coupon for Checkers, plus chances to win R5000 monthly and R50000 annually.
135ZAR

Total

0.00ZAR
I /We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the Banks. I/We also understand that details of each withdrawal will be printed on my bank statement. The reference number will be included in the said payment instruction and if provided to me should enable me to identify the Agreement.
A. MANDATE - I/We acknowledge that all payment instructions issued by you shall be treated by above mentioned Bank as if the instructions had been issued by me/us personally.
B.CANCELLATION - A cancellation niotice of 1 month is required. Should this Authority and Mandate not 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 I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you.
C. 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.
Account Name*
Bank*

ABSA 632005Capitec 470010FNB 250655Nedbank 198765Investec 580105Standard Bank 051001SA Post 460005Bidvest 462005Ithala 754126Old Mutual 462005Tyme 678910Grindrod 584000Discovery 679000African Bank 430000Access Bank 410506
Account number*
Type of Account*

ChequeSavings
Debit Date*

1st7th15th25thLast day of month
Signature

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