Online Debit Order Form
 
 
  Client info:
     
  Title:
  Initials:
  Surname:
  ID No:
  E-mail:
  Tel no:
  Cell no:
  Street name:
  Stand no:
     
  Neighbourhood watch Membership:
     
  Monthly Amount:
  Once off Amount:
     
  Radio Communication :
     
  Once off payment for radio (include VAT):
  Licence fee per monthly R75.00:
     
  DEBIT ORDER DETAILS:
     
  SURNAME AND INITIALS OF ACCOUNT HOLDER:
  NAME OF BANK:
  NAME OF BRANCH:
  BRANCH CODE :
  ACCOUNT NUMBER:
     
 
     
  Saving
  Cheque
  Transmission
     
 
     
  Amount once off :
  Monthly Amount :
     
   
 

Terms and Conditions: I/We hereby request and authorize QBX Systems to draw against my/our
account with the bank (or any other bank or branch to which I/we may transfer my/our account)
the sum of (state amount in words) or any variable amount pertaining this agreement, on the 1st
day of each month. All such withdrawals from my/our bank account shall be treated as though they
had been signed by me/us personally. I/we the undersigned instruct andauthorize you (or your
nominated agent) to draw against my/our account. I/we understand that the withdrawals authorized
here will be processed and I/we also understand that details of each withdrawal will be printed
on my/our bank statement. I/we agree to pay any bank charges relating to this debit order
instruction. This authority may be cancelled by means of giving you thirty days notice in writing
, send by prepaid registered post, but I/we understand that I/we shall l not be entitled to any refund of
amounts which you have drawn whilst this authority was in force if such amounts were legally owing
to you. Assignment: I/we acknowledge that the party hereby authorized to effect the drawing(s) against
my/our account may not cede or assign any of it's rights and that I/we may not delegate any of my/
our obligations in terms of this agreement /authority to any third party without prior
written consent of the authorized party.

   
  I Agree
     
  Yes
  No
   
 


 
Back Back to top
JOIN OUR MAILING LIST
  Join Mailing List
 
  Name & Surname
     
  Email
     
  Mobile no
  Date of Birth