(DD) #56 SS001 – SUITS & SNEAKERS Welcome to the Suits & Sneakers Membership ProgrammeMembership Options:Choose Your Membership*Da Vinci (R99/monthly)Newton (R249/monthly)Einstein (R499/monthly)Your Personal Details:Name* First Last ID Number*Cellphone Number*Landline Number*Email Address* Where are you based?Province*Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern CapeSuburb*City*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 Type*Current (Cheque)SavingsTransmissionAgreement:Abbreviated short name as registered with the acquiring bank: SUITSSNKRSRefer to our contract reference number (“the Contract Reference Number”):Reference*I hereby authorise Vivid Engage (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 Membership 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* Date Format: DD slash MM slash YYYY and thereafter regularly on the:Action Date*1st7th15th20th25thLast dayto the amount of:Da Vinci at R99/monthlyNewton at R249/monthlyEinstein at R499/monthlyIf 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 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 agree that although this authority and mandate may be cancelled by me, such cancellation will not cancel the Agreement. I also 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.AssignmentI 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 BankEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
