Debit Order for domain hosting services

Please print this form, fill it in and fax it to (086)640 1387

Ref by: Magacon 

Debit Order/New service order

 

Name  
Contact number  
Domain name (yourcompany.co.za)  
e-mails   
 
Details of person responsible for payment.
Name  
Postal Address  
Telephone number  

Cell number

  
e-mail address  

Fax Number

  
I hereby request, instruct and authorize Extraordinaire Systems to draw against my bank account as recorded above the relevant hosting fees on a monthly basis and to continue until such time as this instruction has been cancelled by virtue of my/our requesting so in writing, giving one month notice of such requests. All withdrawals from my/our account shall be treated as though they have been signed by me/us personally.

I understand that such withdrawals shall be processed through ACB Magnetic Tape service and shall be printed on my account statement. I agree to pay the bank charges to this instruction. I understand that my service will be suspended and that a reconnection fee of R500.00 will be charge should my service being cancelled due to non payment. Extraordinaire Systems reserve the right not to render a service to web sites which contain adult or violent information.
Banking details:
Acc Name:   Debit day  1      7       14       21       28 
Bank:   Branch:  
Account number   Branch code  
Type of account   Amount  
   

Signed at............................................ on this..................day of..................................2003

Signature.................................................

Assisted by (where legally necessary)...................................................

Please attach cancelled cheque

Please fax this form to (086) 610 4042

Extraordinaire Systems, PO Box 667, La Montagne, 0184.