FIRE Diabetes

The next journey already started. we are accepting late registrations until 15 june 2021

    INSTRUCTIONS:
    ** Please complete all fields.
    ** A copy of the completed form will be sent to the email address you provide.

    DEBIT ORDER FORM

    Fire Diabetes Monthly Membership

    R100/month

    INCLUDES:

    • Feature 1
    • Feature 2
    • Feature 3
    • Feature 4
    • Feature 5
    • Feature 6
    • Feature 7

    I would like to enter into a monthly membership agreement with I Can Function Health as follows:

     
     

    PERSONAL DETAILS

    First Name:

    Surname:

    Title:

    Initials:

    Contact number:

    Email address

     

    Address Details

    Street Address:

    Suburb:

    City:

    Province:

    Postal code:

     
     

    Payment Method

    This information is encrypted for your safety.

    Please debit my account with R100 monthly (tick the box to accept):

    Bank:

    Branch:

    Branch code:

    Account Holder:

    Account no.:

    Account Type:

    Debit on:
    1st15th day of the month

    Start the debit order on (commencement date):

     
     

    Authorisation

    This signed Authority and Mandate refers to our accompanying contract ("the Agreement") as dated on signature thereof ("the Commencement Date"). I hereby authorise I Can Function Health (Pty) Ltd to issue and deliver payment instructions for collection against my abovementioned account at my above mentioned bank (or any other bank or branch to which I may transfer my account to) the sums agreed upon above, commencing on the Commencement Date and continuing monthly until this Authority and Mandate is terminated by me 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 must be issued and delivered monthly on or after the date when the obligation in terms of our Agreement is due. The amount of each individual payment instruction may not be more or less than the obligation due. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement.
    REFUND
    I shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were owing to you according to our Agreement, unless such a request for refund is received within 60 days from the Commencement Date.
    MANDATE
    I acknowledge that all payment instructions issued by you shall be treated by my above mentioned bank as if the instructions had been issued by me personally. I agree to pay any banking charges relating to this debit order instruction.
    CANCELLATION
    I agree that although this Authority and Mandate may be cancelled by me, such cancellation will not cancel the accompanying Agreement, nor the rights and obligations agreed to therein, which Agreement can only be cancelled in writing, by mutual consent.
    ASSIGNMENT
    I acknowledge that this Authority and Mandate has been ceded to NetCash (Pty) Ltd as per I Can Function Health (Pty) Ltd's agreement with NetCash (Pty) Ltd. I acknowledge that the party hereby authorised to effect the drawing against my account may not cede or assign any of its rights and that I may not delegate any of my obligations in terms of this authority to any third party without prior written consent of the authorised party.

     
     

    Type your name to digitally sign this form: