SOSA DEBIT ORDER AUTHORITY/MANDATE

Tel: 011-882-8322
Email: admin@SOSAmedical.org
Business Whatsapp: 011-882-8322
Web Address: www.SOSAmedical.org
Address: 431 Louis Botha Ave. Highlands North, Jhb
Registered as SOS for the Aged NPC (S.O.S.A.) Not for Profit Company No. 2017/330505/08 Public Beneficiary Organisation No. 930062159

Given By:*

(name of account holder)

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

City

Postal CodeCountry

ID Number or Company Reg Number*

Bank Name*

Account Number*

Branch Name*

Branch Code

Type of Account*

Current (Cheque)SavingsTransmissionOther

Amount: (R)*

TO: SOS for the Aged NPC (2017/330505/08) (“SOSA”), 431 Louis Botha Avenue, Highlands North, Jhb, 2192 ABBREVIATED SHORTNAME TO BE USED: SOSA-M REFER TO CONTRACT REFERENCE NUMBER : SOSAMEDICAL613 (“the Contract Reference Number”)

I / We hereby authorise SOSA to issue and deliver payment instructions to your banker for collection against my / our above mentioned 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

Date

and thereafter regularly on*

this 7th day of each month.this 25th day 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 above mentioned bank as if the instructions had been issued by me / us personally.*

I acknowledge the above

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.*

I agree to the above

D. ASSIGNMENT: I / We acknowledge that this authority may be ceded or assigned to a third party if the Agreements also ceded or assigned to that third party.*

I acknowledge the above

Signed*

(signature as used for operating on the account)

On this date

Date

(for office use)
E. AGREEMENT REFERENCE NUMBER.THE AGREEMENT REFERENCE NUMBER IS : SOSAMEDICAL613

Assisting our less fortunate with medical aid hospital plans and care.

“Whoever saves one life is as if he saves an entire world.” (Babylonian Talmud, Sanhedrin 4:5)

Directors: R’ S Wingrin, Dr. C Barlin, S Gordon
Associates: R’ Ari Hoppenstein, Lionel Horwitz

Registered as SOS for the Aged NPC (S.O.S.A.) Not for Profit Company No. 2017/330505/08 PBO No. 930062159 www.SOSAmedical.org

DEBIT ORDER AUTHORITY/MANDATE

Bank Details