Name (Debtor)

_____________________________

Date :

______________________

Address :

_____________________________

_____________________________

Account No as per statement received from Vanslife.com:

______________________

ID Number 

_____________________________

 Abbreviated name as registered with bank:

VANSLIFECC

_____________________________

To Accounts Department Vanslife.com

The details of my/our account are as follows:

BANK :

_____________________________

BRANCH TOWN :

_____________________________

BRANCH NO:

_____________________________

ACCOUNT NAME. :

_____________________________

_____________________________

ACCOUNT NO.

_____________________________

TYPE OF A/C :

____________________________

(Savings, Current, Transmission)

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

 or any variable amount pertaining to this agreement, on the last working day of each month. This being the amount necessary for the settlement of the monthly or once of amount due to you in respect of Domain Name Registration, Website Hosting, Designing, Maintenance, Internet Access Services or any other services as per monthly account submitted to me/us on the last Friday of each month.

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

This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorise 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.

I / We understand that the withdrawals hereby authorised 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.

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.

Signed at _________________ on this _________________ day of _________________ 20__

SIGNATURE AS USED FOR SIGNING MY/OUR CHEQUES ON THE LINE BELOW:

 Please Note: Reconnection fees payable for failed Debit Order transaction: R100.00

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