Just Rewards for Sizwe-Hosmed Members: Electronic Debit Order Agreement

Electronic debit order agreement

Member Name*
First Last
ID Number*
Cell Number*
Email Address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Member Type*
Medical Aid Membership Number
Bank Account Details:
Please provide your bank account information.
Account Holder*
Bank*
Branch Code*
Account Number*
Account Type*
Agreement:
Membership Number*
Broker Name
Broker Reference
Contract Amount*
I/we agree that the first payment instruction will be issued and delivered on:
Start Date*
Date Format: YYYY dash MM dash DD
and thereafter regularly on the:
Debit Day
Terms of Agreement
Abbreviated short name as registered with the acquiring bank: JUSREW I/We hereby authorise Just Rewards for Sizwe-Hosmed Members 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. I/we agree that the first payment instruction will be issued and delivered on the "Start Date" and thereafter regularly on the "Action Day" of each 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 canceled 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. Mandate I/we acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had 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 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. 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.
Signature*
Signature verified by Bank
Comments
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E-Mandate

Electronic debit order mandates for your business.

(DD) #** Just Rewards for Sizwe-Hosmed Members

Bank Account Details:

Agreement: