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Personal Information
Your TitleYour InitialsYour Email*
Your Name*Your Surname*
Work numberYour Cellphone number*
Your Home numberYour Fax number
Courier Delivery Address
Street Address*
South Africa
Payment Method
I will deposit R625 into the following account *
BankBranch/TownBranch #
Standard BankGeorge051001
Account HolderAccount #Account Type
Integrow Health (Pty) Ltd082874778Current
Please debit my account with R299 monthly *
Account Holder*Branch #*
Account #*Account Type*
Debit on the1st 15thof the month.*

This signed Authority and Mandate refers to our accompanying contract (“the Agreement”) as dated on signature thereof (“the Commencement Date”). I hereby authorise Integrow Health (Pty) Ltd to issue and deliver payment instructions for collection against my abovementioned account at my above mentioned bank (or any other bank or branch to which I may transfer my account to) the sums agreed upon above, commencing on the Commencement Date and continuing monthly until this Authority and Mandate is terminated by me by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised must be issued and delivered monthly on or after the date when the obligation in terms of our Agreement is due. The amount of each individual payment instruction may not be more or less than the obligation due. I 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.
I shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were owing to you according to our Agreement, unless such a request for refund is received within 60 days from the Commencement Date.
I acknowledge that all payment instructions issued by you shall be treated by my above mentioned bank as if the instructions had been issued by me personally. I agree to pay any banking charges relating to this debit order instruction.
I agree that although this Authority and Mandate may be cancelled by me, such cancellation will not cancel the accompanying Agreement, nor the rights and obligations agreed to therein, which Agreement can only be cancelled in writing, by mutual consent.
I acknowledge that this Authority and Mandate has been ceded to Netcash (Pty) Ltd as per Integrow Health (Pty) Ltd’s agreement with Netcash (Pty) Ltd. I acknowledge that the party hereby authorised to effect the drawing against my account may not cede or assign any of its rights and that I may not delegate any of my obligations in terms of this authority to any third party without prior written consent of the authorised party.

I agree to these terms *