(DD) #44 NGF001 – NORMAN GOODFELLOWS Your OrderChosen Palette*The Whisky Palette (R899/month)The Wine Palette (R599/month)The Bubbly Palette (R899/month)The Beer Palette (R599/month)The Spirits Palette (R599/month)The Mixed Palette (R599/month)Your Details:TitleMrMrsMsDrProfRevName* Firstname Surname ID Number*Cellphone Number*Home NumberWork NumberEmail Address* Delivery Information:Recipient NameShipping Address*Physical AddressPostal AddressWhere would you prefer your palette be delivered?Physical Address* No. and Street Suburb City Province ZIP / Postal Code We recommend you use a business address where possible.Postal Address* P.O. Box Suburb City Province ZIP / Postal Code Additional Delivery NoteFor Instance - Ask for Sue she can sign for this or hoot at gate. Leave blank if nothing.Payment Method:Pay Using?*Bank AccountCredit CardCoupon?If you have a coupon code, please enter it now.Credit Card Details:Credit Card* American ExpressDiscoverMasterCardVisaJCBMaestro Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name Bank Account Details: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 BANKBranch Code*Account Number*Account TypeCurrent (Cheque)SavingsTransmissionAgreement:Abbreviated short name as registered with the acquiring bank: NGFRefer to our contract reference number (“the Contract Reference Number”):Reference*I hereby authorise Norman Goodfellows (Pty) Ltd 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 18/11/2019, unless this date falls between the 1st and 16th in which case I will be billed the 1st of the next month and thereafter regularly on the 1st of each subsequent month for the amount of:R899 per month until you cancelR599 per month until you cancelIf 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.Signature*Signature verified by Bank This iframe contains the logic required to handle Ajax powered Gravity Forms.