|
KINDERSAFE SAFETY CLUB |
|
Debit Order Application Form
 Please
fax to 086 657 3567 when complete |
| |
|
|
Name and Surname: ______________________________________________ |
|
Email Address: ______________________________________________ |
|
Home / Work Number: _____________________________________ |
|
Name of your child and age: ________________________________________ |
|
|
|
Birthday of your child: ________________________________________ |
|
|
|
Language preference:
Afrikaans/ English |
|
|
|
Address : ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
|
|
|
|
|
|
Amount: R85.00 on the 1st of each month, monthly or until cancelled by
me. |
|
|
|
Bank account: |
|
Bank Name: ____________________________ |
|
|
|
Account Number: ___________________________________ |
|
|
|
Account Type: Savings/Cheque |
|
|
|
Branch Name: ______________________________ |
|
|
|
Branch Code: ____________________________________ |
|
|
|
Name of account holder: _________________________________ |
|
|
|
Credit card: |
|
|
|
Master/Visa Card no: _______________________________________________________ |
|
|
|
Expiry Date: _______________________________ |
|
|
|
CVC No: (last 3 digits on back of card): _________________ |
|
|
|
Name of cardholder: ____________________________________ |
|
|
|
I/We hereby request, “instruct” and authorise Kindersafe cc to draw against
my/our account with the above mentioned bank (or any other bank or branch to
which I/we may transfer my/our account), the amount of R85.00 for payment of
the monthly subscription.
All such withdrawals from my/our bank account by Kindersafe cc shall be
treated as though they had been signed by me/us personally.
This
authority may be cancelled by me/us by giving 30 days written notice, sent
by mail or fax to Kindersafe cc, but I/we understand that I/we shall
not be entitled to any refund of amounts which Kindersafe cc have withdrawn
whilst this authority was in force if such amounts were legally owing to
them. Receipt of this instruction by Kindersafe cc shall be regarded as
receipt thereof by my/our bank (whichever it is or will be).
ASSIGNMENT:
I/WE acknowledge that the party hereby authorised to effect the drawing(s)
against my/our account may not cede or assign any of its rights to any third
party without my/our written consent 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 authorised party.
Signed at ___________________________________ on this the __________ day of
________________________________ 20______
|
|
Please print and fax this form to 086 657 3567 |
Tel:
073 749 6512 Fax: (086) 657-3567 Postal: 7 Morvin Place, Churchstreet,
Durbanville, 7550
E-mail: info@kindersafe.co.za Web: http://www.kindersafe.co.za |
|
We at Kindersafe would like to thank you for your subscription and we hope
you will enjoy collecting the series. |
| |
|
|
|
| |
|
|
|
| |
Kindersafe 2008 © copyright
|