(DD) #55 CHF001 – CHILDFRIENDLY SA Listing Options:TypeCustom Listing Type*Choose Listing Type*Single Listing (R200/month)Provisional 3-Month Single Listing (R200/month)Single Annual Listing (R2000/annually)Up to 3 Outlets Listing (R400/month)Up to 3 Outlets Annual Listing (R4000/annually)More than 3 Outlets (Special Quote)Event Notification Subscription (R3000/annually)Featured Listing Featured (+R100/month) Featured Listing Featured (+R1000/annually) Featured Listing Featured Listing (Value R100 p/m) In which category would you prefer to be listed?Click here to email us for a special quote.Your Company Details:Company Name*As it must appear on the listingCompany Website or Facebook URL*Used for your business descriptionStreet Address of Place of Business*As it must appear on listingCompany Telephone Number*As it must appear on listingCompany Email Address* As it must appear on listingVAT NumberSend Statements to this E-Mail* Your admin of finance departments' e-mailYour Personal Details:Title*MrMsDrProfName* First Last ID Number*Cell Number*Work Number*Email Address* Where did you hear of Child Friendly SA?*A Child Friendly SA representativeSocial mediaPress & radio publicityPamphletD6 School Communicatore-MailA clientCFSA Representative's NamePayment Method:Pay Using*Bank AccountCredit CardCoupon?If you have a coupon code, please enter it now.Your coupon will apply 0% discount.Your coupon will apply 10% discount.Your coupon will apply 25% discount.Your coupon will apply 30% discount.Your coupon will apply 50% discount.Bank Account Details:Account Name*Bank*ABSA BANKCAPITEC BANK LIMITEDFIRST NATIONAL BANKFIRSTRAND BANKINVESTEC BANK LIMITEDNEDBANKSTANDARD BANKABSA-ITHALAAFRICAN BANKALBARAKA BANKBANK OF ATHENSBANK WINDHOEK BEPERKBIDVEST BANK LIMITEDCITIBANKFBC FIDELITY BANK LTDGRINDROD BANK LIMITEDHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDHONGKONG & SHANGHAI BANKINGMERCANTILE BANK LIMITEDMTN BANKING(STANDARD BANK)NEDBANK LESOTHO LIMITEDNEDBANK LTD INC BOE BANKNEDBANK NAMIBIANEDBANK SWAZILAND LIMITEDPEOPLE BANK LTD INC PEP BANKPEOPLES BANK LTD INC NBSPERMANENT BANKSA POST BANK (POST OFFICE)SA BANK OF ATHENSSA RESERVESOCIETE GENERAL JHB BRANCHSOUTH AFRICAN POST OFFICESTANDARD BANK SWAZILANDSTANDARD CHARTERED BANK SASTANDARD LESOTHO BANK LTDSTATE BANK OF INDIASWAZILAND DEV AND SAVINGS BANKTHE ROYAL BANK OF SCOTLAND N.VUBANK LTDVBS MUTUAL BANKBranch Code*Account Number*Account Type*Current (Cheque)SavingsTransmissionCredit Card Details:Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Agreement:Abbreviated short name as registered with the acquiring bank: CFSARefer to our contract reference number (“the Contract Reference Number”):Reference*I/We hereby authorise Childfriendly SA to issue and deliver payment instructions to your banker for collection against my/our above-mentioned account at my/our above-mentioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference Number.The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement.I/we agree that this agreement commences on the "Start Date" below and the first payment instruction will be issued and delivered on the first of the next month. Thereafter, for all monthly agreements, regularly on the 1st day of each subsequent month for a minimum period of 12 months and until cancelled thereafter; and for all annual payment agreements, annually on the anniversary day of the agreement until cancelled, with all listings subject to a 10% annual escalation. Payment instruction will be in the amount of:Contract Amount*Contract Amount*Contract Amount*Contract Amount*Contract Amount*Contract Amount*Contract Amount*Contract amount*I/We agree that the first payment instruction will be issued and delivered on:Start Date* If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid and until this authority is cancelled by me/us by giving notice in writing of not less than three (3) months and sent by prepaid registered post or delivered to your address indicated above.MandateI/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.CancellationI/we agree that although this authority and mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/we also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you.AssignmentI/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party.Signature*Signature verified by BankCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.