DEBIT ORDER

THE FOLLOWING INFO IS REQUIRED

NAME*

E-MAIL*

PHONE*

ADDRESS*

ADDRESS LINE

ADDRESS LINE

CITY

STATE/REGION

ZIP/POSTAL CODE

COUNTRY

AMOUNT
R50R100R200R1000

OTHER AMOUNT

BANKING DETAILS

NAME

SURNAME

ACCOUNT NUMBER

BANK NAME

BRANCH CODE

ACCOUNT TYPE
—Please choose an option—ChequeSavingsTransmission

DEBIT ORDER DATE

TERMS OF SERVICES
I hereby declare that the information provided is valid and I have approved that the stated amount be deducted from my account