75657 xoB OP :latsoP
Service Application Form
2412 015 380 :leT
7425 556 380
|SERVICE APPLICATION AUTHORISATION AND TERMS
The subscriber shall be entitled to terminate this agreement upon two calendar months written notice.
I have read and understood the service terms as published on “http://www.tci.co.za”
Postal: PO Box 75657
Service Application Form
Tel: 083 510 2142
083 655 5247
Fax: 086 610 0913
|BANK DEBIT ORDER INSTRUCTION / CREDIT CARD AUTHORITY
|Abbreviated name as registered with the bank : TCI
The details of my/our account are as follows:
This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement").I / We hereby authorise you to issue and deliver
payment instructions to the bank for collection against my / our abovementioned account at my / our above
mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment
instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing
until this Authority and Mandate is terminated by me / us 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 to be
issued must be issued and delivered as follows
i. On the 1st day ("payment day") of each and every month commencing on _____________. In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;
ii. Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;
I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been
issued by me/us personally.
I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
Signed at ________________________ on this _________________ day of _________________ 20___
Signature ________________________________ Full Name ________________________________
FOR OFFICE USE
This Agreement reference number is: _____________________________________________________________