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Debit Order Form
Join Exact Medical Solutions. Debit My account on the 25th. Debit My account on the 15th.
Debit Order Agreement with Exact Medical Solutions.
Exact Medical Solutions Debit Order Agreement
*(MANDATORY)
Debit Order Date
th Day of every Starting From
Debit Order Instruction
Practice Name
Title
Practice Number
Postal Address
Physical Address
E-mail:
Phone:
Fax:
Cell:
Contact Person
Date:
TO:Exact Medical Solutions c.c.
P.O. Box 5816,
Boksburg North, 1461
Dear Sir
The details of my / our bank account are as follow:
Accout Name: *
Bank : *
Branch: *
Branch Code: *
Account Nr: *
Account Type: *
I / We hereby request, “instruct” and authorise Exact Medical Solutions c.c. 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), for services rendered by Exact Medical Solutions c.c., monthly and in advance,the sum of R (), “ The amount necessary for payment of the monthly Subscription / Instalment / Premiumdue in respect of the above mentioned agreement” on day of each and every month commencing on and continuing until termination of our agreement (as the case may be).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 also agree that an amount of R 25.00 shall be incurred and debited an all debit order transaction rejections, “Unpaid / Insufficient Funds”.
I / We understand that the withdrawal hereby authorised will be processed by computer through a system known as the Bankserv Magnetic Tape Service and I also understand that details of each withdrawal will be printed on my bank statement with reference “EMS” or on an accompanying voucher. I / We agree to pay any bank charges relating to this debit orders instruction. This authority may be cancelled by me / us by giving you thirty days notice in writing, sent by prepaid registered post, but I / we understand that I / we shall not be entitled to any refund of amount which you have withdrawn while this authority was in force if such amounts were legally owing to you. Receipt of this instruction by you shall be regarded as receipt thereof by my / our bank (whichever it is or will be).
ASSIGNMENT:
I / We acknowledge that the party hereby authorised to effect the drawing(s) against my / our account may not cede or assign any of its rights to any third party without my / our prior written consent 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 authorised party.
