Debit Order Request
Registered Company Name:
Company Registration Number:
Authorised person Identity Number:
Alt. Contact Number:
Banking Institution: Bank NameABSAFirst National BankCapitecBidvest BankNedbankStandard BankMercantile Bank
Type of Account: Account Type SavingsCurrent
Frequency Debit Order Date: Date of Debit7th15th25th27thLast Day1st of the month.
Product & Subscription Amount: Web Design & Digital Marketing Services
Agent/ Consultant Name:
HOSTING IN SA (Pty) Ltd
Registration Number: 2016/501694/07
with bank abbreviated name RESAHOSTIN
This signed Authority and Mandate refers to our contract Dated: Day1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st/ MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember/ Year202020212022202320242025 , ‘The Agreement’, I hereby authorise you to issue and deliver payment instructions to your banker for collection against my above mentioned account at my above mentioned bank (or any other bank or branch to which I may transfer my account) on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the Agreement, and commencing on Day1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st/ MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember/ Year202020212022202320242025, and continuing until this Authority and Mandate is terminated by me by giving you notice in writing of not less 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.
The individual payment instructions so authorized to be issued must be issued and delivered as follows: Frequency – choose oneMonthly The amount will be debited with a valid reference on your bank statement.
In the event that the payment day falls on a Sunday or recognized South African public holiday, the payment day will automatically be the preceding ordinary business day. Furthermore, if there are insuﬃcient funds in my account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as suﬃcient funds are available in my account.
Payment Instructions due in December may be debited against my account on Day1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st/ MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember/ Year202020212022202320242025
I understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks. I also understand that details of each withdrawal will be printed on my bank statement. Such must contain a number, which number must be included in the said payment instruction and if provided to me should enable me to identify the Agreement. This number must be added to this form in Section E before the issuing of any payment instruction.
I acknowledge that all payment instructions issued by you shall be treated by my above-mentioned bank as if the instructions had been issued by me personally.
I agree that although this Authority and Mandate may be cancelled by me, such cancellation will not cancel the Agreement. I 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.
I 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.
Signed ONLINE on this Day1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st/ MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember/ Year202020212022202320242025.
!!! Note That All Orders Are Subject To a Successful Debit process. Your Details will be Deleted and/or Blocked from our system after 14 days, in the event of an unsuccessful Debit!!!
For Any Queries Please Not Hesitate To Contact Our support line on +27(0) 31 401 1359 | +27(0) 32 541 0212 | +27(0) 87 654 8677 or email our support department on firstname.lastname@example.org | email@example.com
I have read and agree to all Terms and Conditions for Online Purchases View Terms and Conditions
I Agree/DisagreeAgreeDisagree to the Terms and Conditions of this Online Order.
I Accept/DeclineAcceptDecline the use of Electronic Signature
Website Security Services Acceptance / Decline
We take website security very seriously as it is one of the best things you can do for your online business. Protecting a website will save you a tremendous number of hours (or even weeks) in the event of an attack.
Unfortunately, website attacks are very common and websites of all sizes are targets.
Did you know?
What can our website security services do for you?
Our job is to do our best to secure your website and deter hackers. We can implement specific security measures to protect your website and continuously monitor it to help deter attacks and take immediate action in the event of an attack. This could make the difference of your website being down for a few minutes versus days or even weeks.
Not sure if you need website security services?
If you don’t believe website security is required for your website, ask yourself the following questions:
E. AGREEMENT REFERENCE NUMBER
The AGREEMENT Reference Number: WHD
Leave this empty:
Your legal name
Your email address
Signed by John.M Mason
Signed On: 22/05/2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Debit Order Request
Agree & Sign