Online Application Form | The Lunch Box

Simond Private School Lunch Box

Electronic order form and debit order agreement

Box Type*
Package Type*
Beverage Option*
For kids only.
Package Type*
Beverage Option*
For kids only.
Package Type*
Your details:
Name*
First Name Surname
Cellphone Number*
Format example: 0821234567
Email Address*
Delivery information:
- Recipient Name
- Address*
  Street Address City Postal Code
  
  We recommend you use a business address where possible.
- Additional Delivery Note
  For Instance - Ask for Sue she can sign for this or hoot at gate. Leave blank if nothing.
Payment method:
Pay Using?*
Coupon?
If you have a coupon code, please enter it now.
You will receive R50 off the first month's box for any subscription then carries on at the regular monthly subscription price.
You will receive R100 off the first month's box for any subscription then carries on at the regular monthly subscription price.
You will receive R200 off the first month's box for any subscription then carries on at the regular monthly subscription price.
Bank account details:
Account Holder*
Bank*
Branch Code*
Account Number*
Account Type*
Credit card details:
Credit Card*

MasterCard
Visa
Card Number Expiration Date Security Code (CVV) Cardholder Name
Agreement:
- Abbreviated short name as registered with the acquiring bank: LUNCHBOX
  Refer to our contract reference number (“the Contract Reference Number”):
- Reference*
- I hereby authorise The Lunch Box to issue and deliver payment instructions to your banker for collection against my abovementioned account at my abovementioned bank on condition that the sum of such payment instructions will not differ from my 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 agree that the first payment instruction will be issued and delivered on:
- Start Date*
- and thereafter regularly on the:
- Action Day*
- of each month for the amount due based on the package selected.
- 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 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 acknowledge that all payment instructions issued by you shall be treated by my abovementioned bank as if the instructions had been issued by me personally.
  Cancellation
  I understand that I cannot reclaim amounts, which have been withdrawn from my account (paid) in terms of this authority and mandate if such amounts were legally owing to you.
  Assignment
  I 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 Bank
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Comments
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E-Mandate

Electronic debit order mandates for your business.

(DD) #13 TLB001 – The Lunch Box

Simond Private School Lunch Box

Your details:

Delivery information:

Payment method:

Bank account details:

Credit card details:

Agreement:

Mandate

Cancellation

Assignment