Direct Debit Order Form / Electronic Signature

Direct Debit Order Form

Electronic Signature Submission

Tixibiz (PTY) Ltd t/a SA Domain

A. Authority / Mandate (Electronic)
Please complete all fields below. Your signature will be captured electronically and emailed to SA Domain.

Account Holder Details

Given by (Name of Account Holder)

Street Address

Street Address Line 2

City

Province

Postal / Zip Code

Cellphone Number

Bank Account Details

Account Name

Bank Name

Account Number

Branch Code

Account Type

Amount to be debited

Debit Order Run Date

Please select when the debit order should be processed.

Signature

Use your mouse (left click) to sign. Click Clear if you need to redo it.

(Please provide your SA Domain account number (CIDxxx)

CID Account number or service name

Supporting Documents
(ID, Passport)

Upload Document (PDF/JPG/PNG)

Accepted: PDF, JPG, PNG. Max 5MB.

Tixibiz (PTY) Ltd t/a SA Domain

Debit Order Policy

I/We hereby authorise Netcash (Pty) Ltd to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference Number.

The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement.

The payment instructions so authorised to be issued must carry the Contract Reference Number, included in the said payment instructions, and must be provided to identify the specific contract. The said Contract Reference Number should be added to this form in section E before the issuing of any payment instruction and communicated directly after having been completed.

I /we agree that the first payment instruction will be issued and delivered on 1st of the following month of the date that this document is signed and thereafter regularly on the 1st of every other month.

If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or

Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above.

B. MANDATE
I/we acknowledge that all payment instructions issued by you will be treated by my/our abovementioned bank as if the instructions had been issued by me/ us personally.

C. 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 also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you.

D. 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.

By submitting this form, you confirm the information provided is correct and you consent to the debit order mandate above.

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