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Debit Order Instruction Form
Please debit my account on the day of every month with an amount of payable into the ULA's bank account as follows:
Account Holder: United Liberty Alliance
Bank : ABSA Cheque Account
Branch : Caledon 632005
Swift Code : ABSAZAJJ
Account # :4097574072
I hereby request and authorise you to draw against my/our account with the abovementioned bank (or any other bank or branch to which I/we may transfer my/our account). This being the amount necessary to fulfill the monthly obligation in respect of my/our purchases / contract / agreement as indicated on this form.
All such withdrawals from my/our account by you shall be treated as though they had been signed by me personally.
I/we the undersigned 'instruct' and authorise ABSA Bank to draw against my/our account. I /we understand that if bank details have been supplied the withdrawals authorised here will be processed by ABSA Bank. I/we also understand that details of each withdrawal will be printed on my/our bank statement. I/we agree to pay any banking charges relating to this debit order instruction.
This authority may be cancelled by means of giving you thirty days' notice in writing, sent by prepaid registered post or email, but I/we understand that we shall not be entitled to any refund of amounts, which you have withdrawn while this authority was in force if such amount were legitimately owed to you.
I/we acknowledge that the party hereby authorises 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 authorised party.
Signed in on this day of
LEGAL SIGNATURE/S of ACCOUNT HOLDER
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