Traumatology Services International
Unit 1 Bagley Office Park, Bagley Terrace, Northcliff • Tel: (011) 023 4431
Reg No. 2009/015550/07
Name MEMBERSHIP /
Postal Code DEBIT ORDER FORM
Province
Tel No. of Children
Cell Age of Children
Email Do you Work?
DOB Company Name
Age Position
Who referred you?
I hereby acknowledge and agree to:
1.1 My information as entered is true and correct.
1.2 An EFT deposit is required on signature of order amounting to one month membership
1.3 Signature of this order means the acceptance of our Terms & Conditions
1.4 Cancellation of membership before the 12 months renewal date will result in a 100% cancellation fee.
I/We hereby request, "instruct" and authorise Traumatology Services International (enter bank) _________________________ to draw
against my account with the above mentioned bank ( or any other bank or branch to which I/we may transfer my/our with
the above mentioned bank (or any other account) the amount necessary for the monthly payment due in respect of the above
mentioned agreement on a specific day of each and every month commencing on .................................... for the amount
of R109.00 (forty rand). All such withdrawals from my/our bank account by you shall be treated as though they had been signed
by me/us personally.
I/We agree to pay any penalty bank charges relating to this debit order instruction.
This authority may be cancelled by me/us by giving thirty days notice in writing, after a period of 12 months which can be sent
by registered post, but I/we understand that I/We shall not be entitled to any refund of amounts which you have withdrawn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.
It is further agreed that should a cancellation or notice not be given the debit order instruction will continue from year to year.
It is further agreed that the debit order fee will increase every year by 10%.
Debit Order Bank details:
Bank ………………………………… Branch ……………………………………Branch Code ......…………………………..
Account Name ………………………………………...... Account Type ............................. Date of Deduction: 1st of each month
Account No.: .................................................................... Total Monthly Payment ......R109.00................................................................
TERMS AND CONDITIONS:
1. Traumatology Services International strive to provide the public with accurate and up to date information.
2.All members will represent TSI brand with integrity and respect, and should a Member be find m isrepresenting the Mighty Mom brand will be given immediate notice.
3.This agreement shall continue for a period of twelve (12) months from the commencement date. Should the member wish to can cel this agreement after the initial twelve month period, the
member must do so, giving 30 days notice in writing by fax, with the original termination to be received by Traumatology Services International by registered post. Should this not happen,
it will be deemed that the member wishes to continue with the membership
4. The membership rates will automatically increase by 10% annually, without notice to the member.
5. Traumatology Services International reserves the right to refuse membership to any and all companies and renewal membership may be refused without any reasons gi ven.
6. Traumatology Services International reserves the right to make changes, as and when deemed necessary, to Traumatology Services International
7. Traumatology Services International will ensure that each member is added to the database and constant communication will be sent to the Member.
8. Once this agreement is signed a membershiip number will be allocated to each member.
9. Should a Membership occur through a company that one works for and not directly from the member, it is the company's ownership to notify us in writing via email or fax.
10.Traumatology Services International will not pass on your information to a third party for communication purposes and will only use you details for communication from the Mighty
Mom Offices
Note: A cancelled cheque should be attached for bank identification purposes. (Current Accounts only). Authorisation Code:
Please e-mail signed booking form back to: info@drderryth.co.za
Signature …………………………………………………….
Name …………………………………………………….. Date ............................................................................