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Debit order authority form

Debit Order
SA-Trade (Info)
Support: 073 718 7101
Email: craigh@midvaaltrade.co.za

Dear Sirs/Madam


My Agreement/Account Number (Also your Coupon code)


Name or Company Name:


The details of my/our bank account are as follows:

Branch Name and Town:
Branch Number:
Account Number:

I/We hereby request, "instruct" and authorise DEBITSURE / SA-Trade 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 necessary for the monthly payment due in
respect of the above mentioned agreement on a specific day of each and every month commencing on for the
amount of All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally.

I/We agree to pay any penalty bank charges relating to this debit order instruction.
This authority may be cancelled by me/us by giving thirty days notice in writing, after a period of 1 month which can be sent by
prepaid registered post, but I/we understand that I/We shall not be entitled to any refund of amounts which you have withdrawn while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.

Signed at on the day of year

Signature as used for signing cheques


Assisted by

(Where legally necessary)

Midvaal Trade Partners

Klerksdorp Trade Partners

Trade Partners

Trade partners1