Debit Order Mandate Form - Please Complete

Name *

First

Last

Tel

Cell *

ID Number *

Company Name *

Use website name if you do not have a company name

Website / URL *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Debit Amount per Month *

If you already host with us, we will just add the SSL Certification to your current hosting plan.

** A R500 setup cost will apply to SSL Certification that will be invoiced separately.

Commencement date of first Debit Order

This must be on the FIRST of each month.

Bank Details

Type of Account *

Bank Name *

Branch Code *

Name on Account *

First

Last

Account Number *

CREDIT CARD HOLDERS NAME *

CARD NUMBER *

EXPIRY DATE *

CVV NUMBER * *

* Three digit number on back of card.

CARD TYPE

ASSIGNMENT

I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

Please view the Contract Agreement & the Terms and Conditions here: https://www.klieknet.com/word/legal/ - or click on the Legal tab in the menu.

I Agree. Please tick the box to Agree to the Terms and Conditions.

Date of Agreement *

Comment or Message

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Debit Order Mandate Form - Please Complete

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