Debit

Debit Order Form

Written Authority and Mandate for Debit Payment Instructions

Authority Given by

(Name of Account holder)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank

Branch Code

Account Holder

Date

To (name of beneficiary)

Islamic Medical Association of South Africa

Beneficiary address

36 Hatton Avenue, Sherwood, Durban, 4091

Abbreviated Name and Registered with the Bank

IMA

This Agreement reference number is

3354

Signiture

Print Name Above

I/We hereby authorise you to issue and deliver payment Instructions to your Banker for collection against my/our above-mentioned account 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 In the Agreement and commencing on and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address as indicated above.

Instructions

The individual payment instructions so authorized to be issued must be issued and delivered as follows: monthly, bi-monthly, three monthly, six monthly, annually, weekly, bi-weekly (delete that which is not applicable). In the event that the payment day falls on a Sunday, or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Furthermore, if there are insufficient funds in my account to meet the obligation, you are entitled to track my account and represent the instruction for payment as soon as sufficient funds are available In my account.

Mandate

I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned Bank as if the instructions have been issued by me/us personally.

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 I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you.

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, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

Signed at

On this

Day of

Sign

Print Signiture

Assisted by