Clone of New Imali - Ubuntu TEST

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Product Selection
Checkers Discount Coupons

Up to R5000.00 discount coupons every month from all Checkers and Affiliate Stores
Checkers*

Checkers Discount Coupons
Embedded Funeral Cover

From R 5000.00 to R 20 000.00 cover
Funeral Cover*

Embedded Funeral Cover
Air Time And Data Discounts

Receive discounts on airtime and data on all networks
Data and Airtime Discounts*

Included
Monthly And Annual Prize Draw

Automatic entry into the monthly R 5000.00 draw and then the annual R 50 000.00 draw. Terms and Conditions Apply.
Entry Into Monthly Draw And Annual Draw*

Included
Monthly Premium

ONLY SELECT ONE
Single Member - Checkers/Funeral/Data/Draw/No Nkomo
Single Person - Age up to 65 years old - NO NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R140.00 pmCheckers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R149.00 pmCheckers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R158.00 pm
Single Person - Age up to 65 to 75 years old - NO NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R148.00 pmCheckers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R157.00 pmCheckers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R165.00 pm
Single Person - Age up to 75 to 85 years old - NO NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R201.00 pm
Single Member - Checkers/Funeral/Data/Draw/ Nkomo
Single Person - Age up to 65 years old - INCLUDING NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R148.00 pmCheckers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R159.00 pmCheckers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R180.00 pm
Single Person - Age up to 65 to 75 years old - INCLUDING NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R157.00 pmCheckers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R168.00 pmCheckers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R185.00 pm
Single Person - Age up to 75 to 85 years old - INCLUDING NKOMO

Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R250.00 pm
Family Cover - Checkers/Funeral/Data/Draw/No Nkomo
Family - Age up to 65 years old - NO NKOMO

Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R147.00 pmCheckers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R159.00 pmCheckers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R170.00 pm
Family - Age 65 to 75 years old - NO NKOMO

Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R159.00 pmCheckers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R168.00 pmCheckers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R204.00 pm
Family Cover - Checkers/Funeral/Data/Draw/Nkomo
Family - Age up to 65 years old - WITH NKOMO

Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R169.00 pmCheckers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R177.00 pmCheckers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R186.00 pm
Family - Age 65 to 75 years old - WITH NKOMO

Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R175.00 pmCheckers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R188.00 pmCheckers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R199.00 pm
Authority To Debit
Account In The Name Of*

First NameLast Name
Account type*

ChequeSavingsTransmissionOther
Account Number
Who Do You Bank With*

ABSA Bank: 632 005African Bank: 430 000Bank of Athens: 410 506Bidvest Bank: 462 005Capitec Bank: 470 010Discovery Bank: 679 000FNB: 250 655Investec Private Bank: 580 105Nedbank: 198 765Old Mutual Bank: 462 005Rand Merchant Bank: 261 251RMB Private Bank: 222 026SA Post Bank: 460 005Standard Bank: 051 001Standard Chartered Bank: 730 020Tyme Bank: 678 910
Debit date

1st15th25thLast day of the month
Start Date

MonthDayYear
Date
Do you authorise Valueserv on behalf of Imali - Imali to issue and deliver payment instructions to your Banker for collection against your above-mentioned account at your 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 selected date and continuing until this Authority and Mandate is terminated by you by giving us notice in writing of not less than 20 ordinary working days, in writing. The individual payment instructions so authorised to be issued must be issued and delivered monthly. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day.

Yes client agreedNo client wants more info / does not agree
Agent Name
Should be Empty:

Product Selection

Checkers Discount Coupons

Embedded Funeral Cover

Air Time And Data Discounts

Monthly And Annual Prize Draw

Monthly Premium

Single Member - Checkers/Funeral/Data/Draw/No Nkomo

Single Member - Checkers/Funeral/Data/Draw/ Nkomo

Family Cover - Checkers/Funeral/Data/Draw/No Nkomo

Family Cover - Checkers/Funeral/Data/Draw/Nkomo

Authority To Debit