Name (required):

ID No (required):

Commencement Date (required):

The details of my/our account are as follows:

Payment Reference (IDNO):

BANK (required):

ACCOUNT NAME (required):

ACCOUNT NO: (required):

BRANCH CODE (required):

TYPE OF ACCOUNT: SavingsCurrentTransmission

Email address (required):

This (Authority and Mandate refers to my signature here as ticked off in the Box below. I / We hereby authorize FibreTel S.A. to issue and deliver payment instructions to the bank or debiting company for collection against my / our above mentioned account or purchase at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my/ our obligations as agreed to the above amounts to be deducted, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving FibreTel S.A. notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.

On any day ("payment day") of each and every month commencing on [Commencement Date above]. In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;
I / We understand that the debits hereby authorized will be processed through a computerized Debiting System or Online Credit Payment or Electronic Funds Transfer by the provided by the South African Banks and I also understand that details of each debit will be printed on my bank statement. Each transaction will contain a short abbreviated name (FBSA FEE), which must be included in the said payment instruction and if provided you should be able to identify the Agreement. A payment reference (Identity No) is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you as the Service Provider.

I / We acknowledge that all payment instructions issued by FibreTel S.A shall be treated by my/our above mentioned 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 / we, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which FibreTel S.A. has withdrawn while this authority was in force, whilst such amounts were legally owed to FibreTel S.A.