(DD) #** DLC001 – Durban Laser Clinic Electronic debit order agreement Contact Person* First Last ID Number*Birth Date* Date Format: YYYY dash MM dash DD Gender*FemaleMaleNoneCellphone Number*Email Address* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina 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 Country Bank Account Details:Please provide your bank account information.Account Holder*Bank*ABSA BANKCAPITEC BANK LIMITEDFIRST NATIONAL BANKFIRSTRAND BANKINVESTEC BANK LIMITEDNEDBANKSTANDARD BANKABSA-ITHALAAFRICAN BANKALBARAKA BANKBANK OF ATHENSBANK WINDHOEK BEPERKBIDVEST BANK LIMITEDCITIBANKDISCOVERY BANK LTDFBC 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 RESERVESASFIN BANKSOCIETE 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.VTYME BANK LIMITEDUBANK LTDVBS MUTUAL BANKFINBOND MUTUAL BANKACCESS BANKBANK OF CHINABANK ZEROBNP PARIBAS SA SOUTH AFRICACHINA CONSTRUCTION BANKFINBOND NET1ICICI BANK LIMITEDJ.P.MORGAN CHASE BANK N.ASOCIETE GENERALEBranch Code*Account Number*Account Type*Current (Cheque)SavingsTransmissionAgreement:Membership Package*Contract Reference*Contract Duration*123456789101112131415161718Contract Amount*I/we agree that the first payment instruction will be issued and delivered on:Start Date* Date Format: YYYY dash MM dash DD and thereafter regularly on the:Debit Day1st7th15th25thLast dayTerms of AgreementAbbreviated short name as registered with the acquiring bank: DLC I/We hereby authorise Marinda Steyn t/a Durban Laser Clinic 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 differ as agreed to in the Contract. The payment instructions so authorised to be issued must carry the Contract Reference Number, included in the said payment instructions and must be provided to identify the specific contract. 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 cancelled by me/us by giving you notice in writing. MANDATE I/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. 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. MEMBERSHIP AGREEMENT By signing the membership agreement, you agree to the following terms and condition as set out below: 1. The parties hereby agree that the client has taken out a membership with the salon. 2. Contract duration and automatic renewal: Contract is in force for the number of months from the contract start date (number of payments). 3. That minimum of 3 months commitment will be required. 4. Client will be notified within the last month of active membership via cell phone number of email providing of the expiring contract and the options to renew. 5. Agreement to pay recurring fees: Client agrees to pay recurring fees: Client agrees to pay the Salon monthly recurring fees as authorized via credit card or cheque or savings account charges. 6. Initial payment will be for the first and last month of the contract. 7. Cancellation of contract must be done by either the Client or Salon, with written notification of 30 days in advance of the next billing date. A penalty fee calculated according to the cancellation date and contract time remaining will be charged on contracts cancelled before end date. This will be calculated by salon for services received at individual treatment costs. 8 In order to freeze your debit order or mandate, a completed request must be submitted in writing at least 30 days in advance of the next billing date, which is based on your activation date. 9. Should you not be able to receive treatment, service may be accrued for a maximum of one month ( 30 days). The membership and treatments are not transferable and none of them may be combined with other treatments or specials. 10. All sessions purchased expires within the period it was purchased for. Bookings and appointments have to be cancelled within 24 hours of the scheduled appointments, your services will be cancelled in the case of late cancellation or no show. 11. By signing this agreement the client acknowledges that he/she is 18 years and older, alternatively that a legal guardian has signed on his/ her behalf. 12. The parties hereby consent to the jurisdiction of the Magistrate's court in terms of Section 45 of the Magistrate's Court act No.32 of 1944 ( as amended) notwithstanding the fact that a claim might exceed the jurisdiction of the Magistrate's Court. 13. This agreement constitutes the sole record of agreement between the parties and no variation to this agreement shall be or any force or effect unless reduced to writing and signed by both parties.Signature*Signature verified by BankCommentsThis field is for validation purposes and should be left unchanged.