DEBIT ORDER AUTHORISATION
FROM (Name of Member):
Address :
Postal Code :
Membership no : Date :
E-Mail Address :

TO: KOOPKRAG LIMITED

Dear Sir

INSTRUCTIONS: MONTHLY DEBIT ORDER AUTHORISATION

My bank account’s particulars are as follows:

BANK :
BRANCH NAME :
BRANCH NUMBER :
ACCOUNT NUMBER :

(Please select type of account)

ACCOUNT TYPE: CHEQUE (Current) TRANSMISSION SAVINGS

 

I/We hereby request and authorise you to debit my/our abovementioned account at the above-said bank (or other bank or branch whereto I/we may transfer my/our account) with my monthly account at Koopkrag – "the amount necessary for the payment of my monthly Koopkrag account" on the day of every month.  All such withdrawals by you from my/our bank account will be treated as if signed by me/us personally.

 

I/We understand that the withdrawals authorised hereby will be processed by a computer through a system known as the ACB-magtape service and I/we acknowledge that the particulars of every withdrawal will be printed on my/our bank statement.

 

I/We agree to pay banking costs in respect of this debit order authorisation in the event of costs as a result of the cancellation of the instruction.

 

This authorisation may be cancelled by me/us by giving you thirty days’ notice by prepaid registered post, but I/we acknowledge that I/we will not be entitled to the repayment of amounts withdrawn by you while the authorisation was in force if you were lawfully entitled thereto. An exception will be where it has been agreed with Koopkrag in consequence of an accounting error by a supplier and subject to the existing rules for the payment of accounts.

 

Your receipt of this authorisation is regarded as receipt thereof by my/our bank (as the case may be).

 

This authorisation is valid within the prescribed rules and regulations of membership of Koopkrag Limited.


Signature :
Submission Date :


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