| Iso Leso
Management Services Limited |
|
PO
Box 2127, Creasta, 2118
Tel: (011) 888 4681, Fax: (011) 782 0270 |
|
| ACB
AUTHORITY |
|
| You
are hereby authorised to raise monthly debits to my bank
account detailed below: |
|
| Name of Account Holder |
|
| Practice No. |
|
|
| Bank Details |
| Type of
Account |
|
 |
Current |
|
|
|
Savings |
|
| Name of Bank |
|
| Branch |
|
| Account no. |
|
Bank Clearing Code
(top right corner of cheque) |
|
| Amount to be charged monthly from: |
|
|
(R228.00 - VAT incl. per practice site/ franchise site) |
|
|
The company will charge my account on the 1st (first) and on
the same day of each month thereafter.
It is hereby agreed that this authority will remain in
force until cancelled in writing. |
| SIGNED AT____________________________on______________________________2003 |
|
|
| Signature |
|
|
| PLEASE ATTACH A CANCELLED CHEQUE AND A COPY OF YOUR ID. |
|
| Click on the print button
to print this form |
|
