Application Form

I (Full Name) {Full Name (First):10.3} {Full Name (Last):10.6} confirm that the above information provided is true and correct.

Signature : __________________________________________________

AUTHORITY GIVEN BY

Name of Account Holder	:	{Account Holder Full Name (First):24.3} {Account Holder Full Name (Last):24.6}
Address	:	{Physical Address (Street Address):15.1} {Physical Address (Address Line 2):15.2} {Physical Address (City):15.3} {Physical Address (State / Province):15.4} {Physical Address (ZIP / Postal Code):15.5}
Bank Name	:	{Bank Name:25}
Branch Name	:	{Branch Name:45}
Account Number	:	{Account Number:26}
Account Type	:	{Account Type:46}
Debit Amount	:	{Total (Plan + Extended Members + Extra):40}
Debit Order Frequency	:	{Debit Order Frequency:56}

AUTHORITY GIVEN TO

Name of Beneficiary	:	Mhlangaveza Funeral Services
Address	:	772,4th Road, Marlboro, Gauteng
Bank Name	:	FNB
Contract Reference Number	:	{Branch Name:45}
Contract Date	:	27/07/2024

THE AGREEMENT

I / We hereby authorise Mhlangaveza Funeral Services to issue and deliver payment instructions to the Beneficiary bank for collection against my / our account at my / our bank on condition that the sum of such payment instructions will never differ from my / our obligations as agreed to in the Agreement. The individual payment instructions so authorised to be issued must be issued and delivered {Debit Order Frequency:56} on {Debit Order Date:28} 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. The payment instructions so authorised to be issued must include an Agreement / contract number. This number must be included in the said payment instruction. This number must enable you to identify the Agreement. I / we agree that the first payment instruction will be issued and delivered by the {Debit Order Date:28} (date) and thereafter regularly ACCORDING TO THE AGREEMENT, if 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 to allow for tracking of dates to match with the flow of Credit at no additional cost to myself.

I authorise the originator to make use of the tracking facility as provided for in the EDO system at no additional cost to myself. Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid. This authority may be cancelled by me/us by giving you 30 calendar days written notice.

B. MANDATE

I / we 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. I / we agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

C. CANCELLATION

I / We agree that although this authority and mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / we also understand that I / we can not reclaim amounts, which have been withdrawn from my / our account (paid) in terms of this authority and mandate if such amounts legally owed you.

D. ASSIGNMENT

I / We 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.

I (Full Name) {Full Name (First):10.3} {Full Name (Last):10.6} confirm that the above information provided is true and correct.

Signature : __________________________________________________

Date __________________________________________________