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Kliënt no Titel ID nr Van Volle name Besigheidsadres :Dorp Buurt Srtaat Poskode Posadres

Sel nr Tel nr (B) Faks nr E-pos adres Tipe bedryf Agent Provinsie

Debiet order Rekeningnommer: ……………………………………. Takkode: ………………………Tipe Rekening: …………..……………….

Bank Naam: ………………………………………….. Tak Naam: ……………………………………............................................. Ek/ons versoek en magtig Profiteor om my/ons rekening by die bovermelde bank of by enige bank of tak waarheen my/ons

bankrekening oorgeplaas is of staan te word, met die totale b edrag van R…………………. te debiteer op die laaste dag van elke daaropvolgende maand wat op ……………………… ’n aanvang neem ter betaling van Maandelikse fooi ingevolge hierdie ooreenkoms asook enige ander uitstaande betalings aan PROFITEOR SA verskuldig. Alle sulke onttrekkings vanuit my/ons bankrekening sal geag word om deur my/ons persoonlik gemagtig en gedoen te wees.

Ek/ons verstaan dat die gelde ingevolge hierdie ooreenkoms vanuit my/ons bankrekening onttrek sal word deur middel van ‘n rekenaarmagtige sisteem bekend as die magnetiese banddiens en dat besonderhede van die onttrekking op my/ons bankstaat of op ‘n tersaaklike wyse aangedui sal word. Ek/ons onderneem om enige bankkoste in verband met die bovermelde stoporder te betaal. Ek neem kennis dat die inligting hierop deel vorm van die ooreenkoms tussen die partye soos volledig uiteengesit op die belastingfaktuur. Ek bevestig ook hiermee dat ek nie nadelig beïnvloed is om my lidmaatskap by enige soortgelyke besigheid of organisasie op te sê nie.

Handtekening:………..…………………….Datum:………………….……….Verteenwoordiger: ………... n/ALPHA DOG DESIGNZ

Business Name:_____________________________________________________________________________ About your Business:__________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________ Street View instead of map in detail: YES/NO Telephone:_________________________________________________________________________________ Email:_____________________________________________________________________________________ Contact Owner form button: YES/NO Business Hours:_____________________________________________________________________________ Web Adress:______________________________________________________________________________

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