Debit Order

Debietorder Inligting / Debit order Information

Volle Naam / Full name*
Naam / Name Van / Surname
ID Nommer / ID number*
Selfoonnommer / Cellphone number*
E-pos / E-mail*
Address*
Street Address Address Line 2 City Province Postal
Banknaam / Bankname*
Taknaam / Branchname*
Rekeningnommer / Account number*
Takkode / Branchcode*
Tipe Rekening / Account Type*
Aftrekdag / Withdrawal day*
Month
Day
Year
Bedrag / Amount*
Bedrag in woorde / Amount in words*
Datum / Date*
Toestemming / Consent*
Hiermee verleen ek toestemming om bogenoemde debietorder teen my bankrekening in te stel. / I hereby give permission to place the above debit order against my bank account.
Hiermee verleen ek toestemming om bogenoemde debietorder teen my bankrekening in te stel. / I hereby give permission to place the above debit order against my bank account.