Electronic Debit Order Agreement

The electronic mandate below is a sample. It is fully customisable and may be pre-populated with user data from your own systems. Our electronic mandates can be linked into any existing signup process or payment gateway. We even allow your customers to fill in and digitally sign your existing PDF agreements online and from any web-enabled device. How E-Mandate Works? (Infographic)

We have pre-populated all fields with sample data. Just fill in your email address, then scroll down to sign.

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Email Address*

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Cell Number
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Authority given by:
Name*
First Last
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Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payment Method*
Bank account details:
Real-time bank account validation can be done on form submission by enabling our CDV check module.
Account holder*
Bank*
Branch code*
Account number*
Type of account*
Credit card details:
Credit Card*

American Express
Discover
MasterCard
Visa
JCB
Maestro
Card Number Expiration Date Security Code Cardholder Name
Agreement:
Legal wording can be static or displayed within an agreement textarea (current format).
Abbreviated short name as registered with the acquiring bank: DRCTDBT
Refer to our contract reference number (“the Contract Reference Number”):
Reference*
The reference will be generated on submission
Contract Amount*
I/We hereby authorise Direct Debit to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned 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 the first payment instruction will be issued and delivered on:
Start Date*
Date Format: DD slash MM slash YYYY
and thereafter regularly on the:
Action Day*
of each month.
of each month.
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 or until this authority is canceled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above.
Mandate
I/we acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally.
Cancellation
I/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.
Assignment
I/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.
Terms of Agreement
Abbreviated short name as registered with the acquiring bank: DRCTDBT Refer to our contract reference number (“the Contract Reference Number”). I/We hereby authorise Direct Debit to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned 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 the first payment instruction will be issued and delivered on the "Start Date" and thereafter regularly on the "Action Day" of each month. 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 or until this authority is canceled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above. Mandate I/we acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally. Cancellation I/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. Assignment I/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.
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E-Mandate

Electronic debit order mandates for your business.

(DD) #01 DIR001 – E-Mandate Demo (New)

Authority given by:

Bank account details:

Credit card details:

Agreement:

Mandate

Cancellation

Assignment