GREENTREE TECHNOLOGY (PTY) LTD Application Form
Registration Number: 2007/011089/07 ALL fields to be completed.This form must be printed, signed and faxed to 021 700 4814. Referred by: BizAssist Technologies (PTY) Ltd.
I/We hereby request and authorize you to draw against my/our account with the above mentioned bank (or any other bank to which I/we may transfer my/our account) the sum of (amount in words) ____________________________ or any variable amount pertaining to this agreement, being the amount/s necessary for settlement in respect of our purchases / contract / agreement dated this day (dd/mm/yyyy): ____________________________
First Debit Date (dd/mm/yyyy):
________________________________________
Monthly Debit Date:
________________________________________
Address of Client:
________________________________________
If under 18, Parent/Guardian Signatory Name:
Signatory Name:
________________________________________
Contact Tel of Signatory:
________________________________________
All such withdrawals my/our account by you will be treated as though they had been signed by me/us personally. I/we the undersigned “instruct” and authorize your agent Netcash (PTY) Ltd, to draw against my/our account. I/we understand that details of each withdrawal will be printed on my/our statement. I/we agree to pay any charges relating to this debit order instruction. This authority may be cancelled by means of giving 30 days notice in writing 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prepaid registered post, but I/we understand that I/we shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing to you.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 its rights 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 authorized party.
Signature: ____________________________ on (dd/mm/yyyy): ____________________________
