Debit Order Mandate

Authority and Mandate for payment Instruction: Electronic and Written Mandates 

Abbreviated Name as Registered with the Bank:    PHOXDANCE 

  1. Complete this form with all your contact details and submit.
  2. After having added your details, you will be required to read and accept our terms & conditions enclosed.
For any enquiries please contact accounts@phoxdanceacademy.com
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Email *

Given by (name of Accountholder) 

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ID Number (of Accountholder) 

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Address

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Bank

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Branch and Code 

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Account Number 

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Type of Account 

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Amount

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Date of Debit Monthly (there is only 1 date)

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Mobile Number (Use format starting with country code then drop the 0 for mobile 

eg. 27837082649

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This signed Authority and Mandate refers to our contract (“the Agreement”) dated:
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I/We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my/our above-mentioned 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 date listed below and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address as indicated above. 
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The individual payment instructions so authorised to be issued must be issued and delivered as follows: 

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Terms & Conditions continued
  1. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day. 
  2. Payment Instructions due in December, for January tuition, may be debited against my account on the 20th of the month. 
  3. I / We understand that the withdrawals hereby authorised will be processed through a computerised 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. 

Mandate

I/We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned Bank as if the instructions have 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 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. 

INDEMNITY FORM AGREEMENT

By ticking this box, I declare that I have read, understand and accept the terms and conditions of the above Agreement with Phox Dance Academy.

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A copy of your responses will be emailed to the address you provided.
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