SandavDigital

Sandav Digital (Pty) Ltd
support@sandavdigital.co.za | 010 5020 676
Lot 412 KwaPhezulu Center, Shop 09, Nongoma 3950

Debit Order Authority Form

Please complete this form to authorise a recurring debit order against your bank account.

Client Details

Full Name / Company Name

Physical Address

Cellphone Number

Email Address

Debtor ID Type

Debtor ID Number

Account Holder Name

Bank Name

Account Number

Branch Code

Account Type

Debtor Telephone Number

+27

Additional SMS Notifications

Debtor Email Address (if different)

Internet Package / Plan

Monthly Amount (R)

Debit Order Date (1–31)

Reference / Account Number

The Client confirms that the banking details provided are correct.
The Client agrees that sufficient funds will be available on the agreed debit date.
Failed debit orders may result in service suspension and additional bank charges.
Sandav Digital reserves the right to re-submit unpaid debit orders.
Cancellation of this debit order must be done in writing.
This authority forms part of the service agreement between the Client and Sandav Digital (Pty) Ltd.

I / We acknowledge that I / We understand and agree to the terms of this Debit Order Authority.

Client Full Name

Signature

Sign here — use your finger, stylus or mouse

Sign inside the box above.

Please provide your signature.

Date

For office use: Merchant Name: Sandav Digital (Pty) Ltd · Merchant Number: 25500018729

Complete all required fields and sign to enable submit.