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Name
Date
ID Number / Registration Number
Name & Surname / Company Name
Address
Code
Contact Details
Home Number
Mobile
Work Number
If Company/CC, Name of person(S) signing this:
Account Holder Name
Bank
Account Number
Branch Code
Account Type
Current
Savings
Cheque
Transmission
Other
If Other
Transaction Type
AEDO
NAEDO
MPS
DEBICHECK
COLLECTION INSTRUCTION
Interval
ONCE OFF
MONTHLY
QUARTERLY
BIANNUALLY
ANNUAL
WEEKLY
BIWEEKLY
Is this limited to fixed amounts or variable amounts
Fixed Amount
Variable Amount
NOTE: if variable, the hereunder may exceed
ONCE OFF TRANSACTION
Collection Date
Amount Rand
Recurring Transactions
Continue indefinitely until cancelled by the debtor
YES
NO
1st Collection Date
Amount Rand
Day of the month thereafter (1-31)
Annual Escalation (%)
Escalation month
If not Indefinite (number of deductions)
Final Date
If weekly
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I/We, the above-mentioned and undersigned, hereby authorise Ramapela Funerals (Nu Pay System) to collect by debit order from the above-mentioned bank account.
(I confirm that I/We are the person(s) with signature authority as registered with my/our bank.
Copy of ID
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