(DD) #00 DDL001 – Direct Debit (Signup) Application reference*For office use only.Specific industry*OtherMicro LenderDebt CollectorLoan BrokerInsurance BrokerFuneral ParlourNature of business*You will not be able to apply online due to your industry. Please contact us at email@example.com.Business informationCompany name*Company registration number*Trading address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe VAT numberWebsite Contact informationName* First Last Landline numberCellphone number*Email address* Application detailsServices required* Debit Order NAEDO AC (DebiCheck) Credit / Debit Card AVS E-Mandate Unsure Quote will be provided for the setup of E-mandate service.Preferred username*Mother's maiden name (security question)*Email address used for admin notifications* Debit order amounts to customers*Vary monthlyStay the same every monthDependsWhich operating system do you use?*WindowsmacOSLinuxAggregate limit*Total amount collected in 1 month.Item limit*Highest amount for 1 customer.Shortname*Unique company identifier (usually legal entity or trading as name).Payment detailsSpecify if you make use of voice mandates? My business is in the call center industry and I make use of voice mandates. Application fee Price: R449.00 Application fee Price: R1,137.00 Coupon Code Do you have a discount coupon?How would you like to pay?Credit CardBank Transfer (EFT)Please make payment to:Direct Debit (Pty) LtdFirst National BankAccount number: 62361026943Branch code: 250655Account type: CurrentUse your unique "Application reference" at the top of this form "DD1066EM" as payment reference.Payment information* American ExpressDiscoverMasterCardVisaJCBMaestro Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name Terms of agreement*Abbreviated short name as registered with the acquiring bank: "DIRECT DEBIT"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 below:I understand that by submitting my application I agree to pay a once-off non-refundable application fee and timeously supply all documentation requested in order to perform satisfactory vetting of my business.I acknowledge that I do not have a bad credit history and that any defaults and judgments in my business and/or personal capacity may count against me and affect your final decision.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.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.MandateI/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.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. I agree to the terms of agreement Total due immediately R0.00 Signature*Signature verified by BankNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.