(LS) #** SL002 – SLATER (ONLINE) Electronic debit order mandate Email Address* Club (Slaters Gym Branch)Three RiversVanderbijlpark TownVanderbijlpark SW5SebokengWelkomSasolburgVereenigingCorporateFundraiser NamePromo CodeNot compulsoryCompany NameNoneSAPSTransactionNewRenewalTransferAre you paying for*YourselfSomeone elseYourself and someone elseMain Member Details / The Person Paying:Name* First Last ID or Passport Number*Medical Aid NameMedical Aid NumberFind address using Google MapsResidential Address Street Address Complex / Estate, Home Number & Internal Street 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 Find address using Google MapsWork Address* Company Name Complex / Estate, Home Number & Internal Street 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 Cell Number*Work NumberAccess Card NumberContract:One months written notice after expire.Contract Period*61224Month(s)Contract Type*Off-PeakPrime TimeCorporateV-Day SpecialOff-PeakOFF-PEAK SINGLE 12 MONTH - R219pmOFF-PEAK SINGLE 24 MONTH - R169pmPrime TimePRIME TIME SINGLE MONTHLY - R359pmPRIME TIME SINGLE 6 MONTH - R319pmPRIME TIME SINGLE 12 MONTH - R269pmPRIME TIME SINGLE 24 MONTH - R219pmPRIME TIME COUPLE 6 MONTH - R479pmPRIME TIME COUPLE 12 MONTH - R429pmPRIME TIME COUPLE 24 MONTH - R379pmPRIME TIME SINGLE 6 MONTH (SPECIAL) - R299pmPRIME TIME SINGLE 12 MONTH (SPECIAL) - R249pmPRIME TIME SINGLE 24 MONTH (SPECIAL) - R199pmPRIME TIME COUPLE 6 MONTH (SPECIAL) - R459pmPRIME TIME COUPLE 12 MONTH (SPECIAL) - R409pmPRIME TIME COUPLE 24 MONTH (SPECIAL) - R359pmPRIME TIME FAMILY 6 MONTH (SPECIAL) - R459pmPRIME TIME FAMILY 12 MONTH (SPECIAL) - R409pmPRIME TIME FAMILY 24 MONTH (SPECIAL) - R359pmDISCOVERY SINGLE 12 MONTH - R209pmDISCOVERY SINGLE 24 MONTH - R199pmDISVOVERY COUPLE 12 MONTH - R369pmDISVOVERY COUPLE 24 MONTH - R359pmDISCOVERY FAMILY 12 MONTH - R429pmDISCOVERY FAMILY 24 MONTH - R419pmCorporateCORPORATE SINGLE CLUB SINGLE MEMBERSHIP 24 MONTHS - R169pmCORPORATE SINGLE CLUB SINGLE MEMBERSHIP 12 MONTHS - R209pmCORPORATE SINGLE CLUB SINGLE MEMBERSHIP 24 MONTHS - R189pmCORPORATE SINGLE CLUB SINGLE MEMBERSHIP 12 MONTHS - R239pmV-Day SpecialV-DAY SPECIAL 6 MONTHS - R449pmV-DAY SPECIAL 12 MONTHS - R399pmV-DAY SPECIAL 24 MONTHS - R349pmDiscovery Vitality Membership NumberJoining FeeJoining Fee (All Goods) - R500Joining Fee (Selected Goods) - R200Joining Fee (12 Months) - R150Joining Fee (24 Months) - R100Zero Joining Fee - R0Transfer Fee - R150Off Peak Joining Fee (x1) - R100Off Peak Joining Fee (x2) - R200Off Peak Joining Fee (x3) - R300Secondary Member Details:Complete if you're applying for a secondary member.Name First Last Cell NumberChildren DetailsNameID NumberDate of BirthAccess Card Number Work NumberSecondary Member Access Card NumberPromo Items (Free):Access Card Normal Price: R0.00 Quantity: Access Card Premium Price: R0.00 Quantity: Water Bottle Price: R0.00 Quantity: Towel Price: R0.00 Quantity: Cap Price: R0.00 Quantity: Bag Price: R0.00 Quantity: Once-off Amount Price: R0.00 Do you need any paid promo items?NoYesPromo Items (Paid):Access Card Normal Price: R50.00 Quantity: Access Card Premium Price: R150.00 Quantity: Water Bottle Price: R10.00 Quantity: Towel Price: R80.00 Quantity: Cap Price: R80.00 Quantity: Bag Price: R100.00 Quantity: Once-off Amount Price: R0.00 Debit Order Details:Monthly Amount Price: R0.00 Start date for your contract* Date Format: DD slash MM slash YYYY Debit Day Every Month*115202223252627282930Last working dayPayment Method:Payment MethodBank AccountCredit CardBank Account Details:Type of Account*Current (Cheque)SavingsTransmissionBank*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 BANKINGHSBC BANKOM BANK LIMITEDCAPITEC BUSINESSMTN 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*Name of Bank Account Holder*Credit Card Details:Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name Agreement:Abbreviated short name as registered with the acquiring bank: SLATERA once off annual levy of R88 will be charged in the Nov/Dec period to keep your membership the same for as long as you're a member. This means no yearly increases in fees.If your debit date falls over a weekend or public holiday, you will be debited the day before the weekend or public holiday.You first debit order will go through on the next upcoming day of your choice. Refer to our contract reference number (“the Contract Reference Number”):Reference*Terms and Conditions*DEBIT ORDER AUTHORISATION I/We hereby authorise Slater Health (hereinafter “the Company”) to issue and deliver payment instructions to my/our bank for collection against my/our above-mentioned account, provided that the aggregate of such instructions shall not exceed my/our financial obligations under the Membership Agreement. I/We acknowledge that such debit order transactions will be processed through a computerised payment system operated by South African banks, and that each transaction will be reflected on my/our bank statement. Receipt of this authorisation by the Company shall be deemed receipt by my/our bank. In the event that a scheduled debit order date falls on a non-processing day (including Sundays and public holidays), I/we consent to the payment being debited on the preceding business day. I/We further authorise the Company to utilise the tracking facility provided within the EDO (Early Debit Order) system at no additional cost to me/us. MANDATE I/We acknowledge that all payment instructions issued by the Company will be treated by my/our bank as if they were personally issued and authorised by me/us. CANCELLATION OF AUTHORISATION I/We understand and agree that while I/we may cancel this debit authorisation, such cancellation shall not constitute cancellation of the underlying Membership Agreement. I/We acknowledge that any amounts legally owing to the Company under this mandate and debited from my/our account are not eligible for reversal. Written notice of cancellation must be received no less than one calendar month prior to the intended cancellation date. The authorisation will remain in force on a month-to-month basis following expiry of the fixed period unless I/we provide a written cancellation notice at least twenty (20) business days prior to the next scheduled debit order. Cancellations must be submitted by email to cancellations@slatergyms.co.za or by completing the official cancellation form available at the gym. EARLY SETTLEMENT OPTION I/We may, at my/our discretion, settle outstanding obligations early by making direct payments. I/We confirm that the listed account complies with the Financial Intelligence Centre Act (“FICA”). ASSIGNMENT I/We acknowledge that this authorisation and mandate may be ceded or assigned to a third party, provided the underlying Membership Agreement is also ceded or assigned to such third party. PENALTY FEES In the event of a failed debit order, a penalty fee of R50.00 will be added to the following month’s account, payable by EFT or in person at any Slater Gym. This penalty will not be debited automatically from my/our bank account. In the event that a debit order processed through the EFT banking system is unsuccessful for any reason, the Company reserves the right to re-present the debit order on an alternative date, which may be up to one (1) day earlier or one (1) day later in the following month. The Customer remains responsible for ensuring that sufficient funds are available in the designated account on the due date and any alternative date of presentation. The Company shall not be liable for any bank charges, penalties, or fees incurred by the Customer as a result of an unsuccessful debit order.” I/We accept liability for all legal and collection costs incurred by the Company in recovering any outstanding amounts. This agreement is enforceable for the fixed period stated herein. The debit order reference will reflect as “SLATER” on my/our bank statement. CANCELLATION FEE This Agreement was duly completed and signed by me/us, and all information provided is accurate and true. I/We understand that I/we have the right to cancel this Agreement within five (5) days, excluding the day of signing, Saturdays, Sundays, and public holidays. Thereafter, early cancellation prior to the contract end date will incur a cancellation fee equivalent to 50% of the remaining balance of the Agreement. ANNUAL FEE I/We acknowledge and agree to an annual fee of R88.00, which will be debited during the November/December period. This fee secures the fixed membership rate for the following year, with no annual increase applied. MEDICAL FITNESS AND LIABILITY WAIVER I/We declare that I/we am/are medically and physically fit to engage in physical exercise. I/We acknowledge that the Company shall not be liable for any injury, loss, or damage sustained while using Club facilities. I/We confirm that the essential terms of this Agreement have been explained to me/us in a language that I/we understand, and that I/we understand the implications thereof. This Agreement constitutes the entire agreement between the parties, and no amendment, variation, or cancellation shall be of any force unless reduced to writing and signed by both parties.Club Rules and Regulations*All members shall comply with the Club’s rules and regulations, as prescribed by management. These may be amended from time to time and communicated either verbally or via signage within the Club premises. MEMBERSHIP ACCESS CARD Membership/Access Cards are non-transferable and may only be used by the registered member. No access shall be granted without the card. If a card is presented by a non-member, the card will be confiscated, and the member’s access may be suspended or terminated. A replacement fee may be charged for lost or stolen cards. If forgotten, access will only be permitted upon presentation of an ID or driver’s license, and only once every three (3) months. The Club reserves the right to deny access to any member who is in arrears or otherwise in breach of this Agreement. DRESS CODE AND HYGIENE Members must wear appropriate attire in line with the Club’s image and regulations. No topless training is permitted, including by male members. Members must use a personal towel during workouts and wipe equipment after use. AGE RESTRICTIONS - No person under 12 years may enter any training area. - No person under 16 years may use cardiovascular equipment (treadmills, rowers, cycles, etc.). Minors (12–18 years) may only train under specific membership plans and conditions, possibly requiring adult supervision. Childcare facilities are available at designated times, as advertised. MEDICAL AID MEMBERSHIPS Medical Aid memberships are valid only while an agreement exists between Slater Health and the respective Medical Aid provider and while payments are received. Such memberships are non-transferable and may be cancelled at the instruction of the respective Medical Aid. FREEZING OF MEMBERSHIPS Memberships may be frozen for medical or travel reasons only, for a minimum of one (1) month and maximum of three (3) months per 12-month cycle. Only prepaid memberships may be frozen. Debit order memberships are excluded. RECIPROCAL CLUB USAGE Members may access other Clubs within the Slater Group under the reciprocal agreement. Members are advised to confirm participating locations with reception. The Company does not guarantee access to third-party clubs using the Slater name and is not liable for any inconvenience caused by their unavailability. 17. DAMAGE TO CLUB PROPERTY Members shall be held liable for any damage caused—whether intentional or accidental—to Club property. 18. CLOSURE OR ALTERATION OF CLUB OPERATIONS The Club may permanently close or temporarily close for maintenance or upgrades. In the event of permanent closure, Slater Health reserves the right to provide an alternative facility within a 20 km radius. Operating hours may be adjusted at the discretion of Club Management. Equipment and class availability are subject to demand and may be modified or discontinued. 19. PRE-OPENING AGREEMENTS Slater Health may enter into agreements with prospective members for clubs under construction. While the Company endeavours to meet opening timelines, it does not guarantee any specific opening date. Memberships shall commence on the official opening date of the Club. 20. PERSONAL PROPERTY The Club shall not be held responsible for any loss, theft, or damage to personal property belonging to members, their dependents, guests, or any third party. By signing this Agreement, the member acknowledges full understanding and acceptance of the Terms and Conditions outlined above.Signature*Signature verified by Bank