(DD) #41 MOI001 – MoiMooi MoiMooi electronic membership application and agreement form Step 1 of 3 33% Welcome to MoiMooiMoiMooi has introduced its revolutionary concept of making beauty treatments for gents and ladies available to all. As a MoiMooi member, your small monthly fee ensures that you have access to up to FIVE free beauty treatments every month. You would usually pay up to R600-00 per treatment if you used a traditional beauty salon. We offer a one-stop beauty shop from hair to waxing to massages. Any of these treatments are free as a paying member.MoiMooi is our salon service provider to our members. All of MoiMooi's therapists are professionally trained and accredited thus providing the level of service you would expect from a 5 star salon. MoiMooi uses only the best products available to ensure a therapeutic and relaxing experience.To sign up for the MoiMooi Membership you will need to complete the following 2 easy steps:Membership detailsPayment details (authorize bank debit, securely, online) + eSignature Membership detailsEmail Address* Sales AgentReferral CodeID Type*National IDBirth CertificateSA IDCompanyCountry of Issue*ID / Passport / Registration Number*Name & Surname / Company Name*Occupation*Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Number*Mobile Number*Work Number*If Company/CC, Name of Person(s) signing this*Emergency Contact* First Last Emergency Contact Number* Payment detailsCoupon CodeEnter valid coupon code to apply discountCoupon code applied.About your membership and feesOnce-off Registration Fee: R200.00Monthly Fee: R899.00About your membership and feesOnce-off Registration Fee: R200.00Monthly Fee: R699.00About your membership and feesOnce-off Registration Fee: R200.00Monthly Fee: R499.00About your membership and feesMonthly Fee: R499.00And you may commence your treatments in the month that your registration fee is payable.A welcome email will be sent to you, which will include your Membership number, information on how to book and contact details.Account holder (debtor) informationAccount Holder Name*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 BANKBranch Code*Account Number*Account Type*CurrentSavingsTransmissionOtherIf "Other" please specify*Collection instructionReference*IntervalMonthlyOnce-offQuarterlyBi-AnnuallyAnnuallyWeeklyBi-WeeklyIs this limited to a fixed amount, or to debits due in future that may vary?Fixed amountsVariable amountsContract amount: R899.00Contract amount: R699.00Contract amount: R499.00Contract Amount*Continues indefinitely until cancelled by debtor?YesNoStart Date*Collection Date*7th15th20th25thLast DayI/We, the above mentioned and undersigned, hereby authorise StratCol to collect by debit order from the above mentioned bank account, all amounts due in terms hereof and to pay same to the StratCol User below.Terms of Agreement*AgreementI/We hereby authorise Stratcol to issue and deliver payment instructions to my/our banker for collection against my/our abovementioned account at my/our abovementioned bank.STRATCOL USER NO: 1114776STRATCOL USER NAME: BEE WITH US (PTY) LTDSTRATCOL ABBREVIATED NAME: GO(this will be the name appearing on your Bank statement)STRATCOL USER PHYSICAL ADDRESS:264 Victoria RoadWoodstockCape TownSouth AfricaThe individual payment instructions so authorised to be issued, must be issued and delivered according to the abovementioned interval 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.The payment instructions so authorised to be issued, must carry a number, which number must be included in the said payment instruction and if provided to me/us should enable me/us to identify the agreement on my/our bank statement. The said number should be added to this form before the issuing of any payment instruction and communicated to me/us directly after having been completed by me/us.I/We agree that the first payment instruction will be issued and delivered as per collection instruction.If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I/We agree that the payment instruction may be debited against my/our account on the following or previous business day.NAEDOAllows for tracking of dates to match with flow of Credit at no additional cost to myself/ourselves. I/We authorise the originator to make us of the tracking facility as provided for in the EDO system at no additional cost to myself/ourselves.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.General Terms and ConditionsThere is a five-day cooling-off period.Bookings are essential and no walk-in treatments will be accommodated.Dishonoured bookings will be recorded as redeemed.Your membership entitles you up to five treatments per calendar month. Unused treatments will not be carried over.The maximum treatment amount allowed is one per client per day (subject to appointment only).Cancellation is subject to a written notice of 30 days prior to the intended date of cancellation subject to a cancellation fee.Memberships are subject to an annual administration fee, which will be deducted in December.There is a yearly membership subscription increase which takes affect on your anniversary month.Payment dates on a Sunday or recognised South African public holiday , will automatically fall on the next ordinary business day, this is also applicable in December.Where there are insufficient funds, we will re-present the instruction for payment as soon as the funds become available.The Authority and Mandate may be terminated by the member, however, this does not cancel the Agreement (membership).You will not be entitled to any refund of the amounts withdrawn while the Authority (debit order) was in place, if such amounts were legally owing by you.The Authority and Mandate may be ceded or assigned to a third party only if the Agreement is also ceded to a third party.AcknowledgementsI understand and acknowledge that my membership is subject to full terms and conditions which may be viewed at www.moimooi.com or I can obtain a copy by calling the MoiMooi Call Centre on 087 625 0626. MoiMooi may cancel my membership if I do not comply with my Contract or Spa Rules.I hereby apply to become a member of MoiMooi as per the Terms and Conditions as set out on the Application Form and Debit Order Mandate.I confirm that I/we are the person(s) with signature authority as registered with my/our bank. I agree to the Terms of Agreement Signature as used for operating on the accountSignature verified by Bank This iframe contains the logic required to handle Ajax powered Gravity Forms.