Pretoria Business Brokers 
508 Atterbury rd,  Pretoria 0081      Tel 012-361 0576     Fax 0866 124 303         083 281 2709     louis-k@mweb.co.za

BANK DEBIT ORDER INSTRUCTION – CREDIT CARD AUTHORITY

 Name (Debtor)   _____________________                                            Date                   __________/_______/2008                           

 Address                ____________________                                             Signatory name  ______________________

                               _____________________                                            Contact Tel         ______________________

 Dear Sirs/Madams The details of my bank account are as follows:                           CREDIT CARD TRANSACTIONS only below

 

BANK                      _______________________________

BRANCH/TOWN  _______________________________

 BRANCH NO.       ______________________________  

 ACCOUNT NAME ______________________________

 ACCOUNT NO.    _______________________________

 TYPE OF A/C        _______________________________                                                                                                      

 

CARDHOLDERS NAME  __________________________               

 

CARD NUMBER         _____________________________

 

EXPIRY DATE            _____________________________     

 

CVV NUMBER            _____________________________

 (three digit number on back of card)                 

CARD TYPE                ____________________(Master/Visa)

I/we hereby request and authorize you to draw against my/our account with the abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of (state amount in words)  ___________________________________________________________________ or any variable amount pertaining to this agreement, on the first working day of each month. This being the amount necessary for the settlement of the monthly due to you in respect of our purchases/contract/agreement dated    ___      / ______     / ______     .

All such withdrawals from my/our account by you shall be treated as though they had been signed by me/us personally.

I/we the undersigned "instruct" and authorize your agent Netcash (Pty) Ltd, to draw against my/our account. I/we understand that if bank details have been supplied the withdrawals authorized here will be processed by BankServ.  I/we also understand that details of each withdrawal will be printed on my/our statement.

I/we agree to pay any banking charges relating to this debit order instruction.

This authority may be cancelled by means of giving you thirty days notice in writing, sent by prepaid registered post, but I/we understand that I/we shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing to you.

Assignment:  I/We acknowledge that the party hereby authorized to effect the drawing(s) against my/our account may not cede or assign any of its rights and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party without prior written consent of the authorized party

Signed at                  ___________________     on this ___            day of ____   _________________               2008.  

_________________________________  (Initials and Surname) ____________________________________

SIGNATURE AS USED FOR SIGNING CHEQUES OR CREDIT CARD VOUCHERS

Please print, complete, sign and fax this Instruction to us at 0866 124 303