Ready to submit your Debit order form? We have an option for everyone! Manual Submission Online Submission Online Submission Customer InformationFirst Name *Last Name *Company NameSA Identification Number *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodePostal AddressInstall Date *Commencement Date *Contact Number *Cell NumberEmail AddressSelect *PackageCapped Wireless - 20 gigs - R250Capped Wireless 50 gigs - R350Capped Wireless 100 gigs - R450Capped Wireless 200 gigs - R550Capped Wireless 300 gigs - R650Uncapped Premium Wireless 4/2 Mbps - R450Uncapped Premium Wireless 10/2 Mbps - R650Uncapped Premium Wireless 12/10 Mbps - R800Uncapped Premium Wireless 15/10 Mbps - R1000Uncapped Premium Wireless 20/10 Mbps - R1200Uncapped Premium Wireless 30/15 Mbps - R1500Debit Order InstructionsDear Sir/MadamThe details of my/our account are as follows:Bank *Branch Town *Branch Code *Account Name *Account Number *Account Holder *Account Type *Debit Amount *Terms and ConditionsThis signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorize you to issue and deliver payment instructions to the bank for collection against my / our abovementioned account at my / our above mentioned 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 commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 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 on one of the following dates. ( 1st / 5th / 7th / 15th / 25th / 30th )On the1st5th7th15th25th30thof each and every monthCommencing onIn the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated 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;DEBIT ORDER CONSENT * I / We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We 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. EQUIPMENT LEASE AGREEMENT *The equipment remains the property of Vryheid Wireless (Pty) Ltd. The provider (Vryheid Wireless (Pty) Ltd) does not take responsibility for damage to equipment by lightning, fire, negligence, etc. It is the responsibility of the client to replace damaged equipment at own cost and / or take out insurance covering damage to equipment.MANDATE *I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.CANCELLATION *I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We 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.ASSIGNMENT *I / We acknowledge that this Authority may be ceded to 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. Submit Manual Submission Download the Form Here: Please fill out the form and resubmit in the area on the Right. Download Form Upload Form Here:Choose FileNo file chosenDelete uploaded file Submit
