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DEBIT ORDER INSTRUCTION AND AUTHORISATION

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					                     DEBIT ORDER INSTRUCTION AND AUTHORISATION

                                                                                                  Tel: 0860 77 11 77          Fax: 086 511 5219
                                                                                                  Postal Address:
                                                                                                  P.o. Box 3066, Durbanville, 7550
                                                                                                  Fiscal Address:
                                                                                                  Tygervalley chambers, Block E, Unit 12,
                                                                                                  Willie van Schoor ave, Bellville, 7530
                                                                                                  info@genesistrust.co.za

GENESIS TRUST REF: _______________________________________
Surname: _____________________________________________                         Full Names: ___________________________________________
ID:       _____________________________________________
Cell:     _____________________________________________                        Tel:    _______________________________________________
E-mail:   _____________________________________________                        Fax:    _______________________________________________
Address ___________________________________________________________________________________________________________
          ______________________________________________                       Postal code: __________________________________________


DEBIT ORDER INSTRUCTION AND AUTHORISATION
Name of account: ____________________________________________________________________________________________________
Account type: ___________________________________________
Account number: ________________________________________                       Branch code: __________________________________________
Bank name: _____________________________________________                       Branch: _______________________________________________
Deduction day in the month (Any working day of the month is allowed for deductions, choose one)
Date of first deduction ______/_____/20____ Amount to be deducted with first deduction R______.___
Date of second deduction ______/_____/20____ Amount to be deducted with second deduction R______.___
Recurring deduction amount after the second month R ______.___ for ________ successive months or un till cancelled YES / NO
If applicable, last deduction date: _____/_____/20____ and amount if different from recurring amount above R______.___
Annual escalation: _______%


I/We, the client or the duly authorised representative thereof (“the CLIENT”), hereby authorise the entity mentioned below (“GENESIS
TRUST”), STRATCOL LTD and/or its agents, to collect by means of electronic debit from the above account or from any other account in the
name of the CLIENT at the same or any other bank, all or any monies due by the CLIENT to GENESIS TRUST as principal debtor or surety or
for any other reason, and to pay same to GENESIS TRUST . The authority so given is restricted to the amount mentioned above and may be
deducted on the mentioned deduction day or within 7 working days thereafter.
I accept the following to be applicable hereto:
1.        This authorisation may only be withdrawn with 30 (thirty) days written notice to GENESIS TRUST at its physical address;
2.        I and/or the CLIENT, individually and collectively, indemnify and hold harmless GENESIS TRUST, STRATCOL LTD and/or its
          agents against any claim of any nature arising from the electronic debit or transfer or from any other cause following this authorisation
          and irrespective whether such authorisation had been withdrawn or not;
3.        In the event of the relevant account not having sufficient cleared funds to meet any debit, I am aware that a fee will be debited against
          the clients account by the bank and GENESIS TRUST relating to the return of the debit and I accept the responsibility to ensure
          sufficient cleared and available funds to the minimum of the limit above (or as amended from time to time).
4.        Any reference to the entities above includes a reference to any successor in title or in appointment;
5.        This authorisation is not an amendment to any specific arrangement regarding payment of accounts and serves merely as an
          payment is received by GENESIS TRUST; and
6.        Should any dispute arise about GENESIS TRUST right to collect any amount in terms hereof, the client shall have the onus to instruct
          his bank to refuse or return any debit as unpaid.




Date: _________________________                                      Signature: ___________________________________________________


GENESIS TRUST STRATCOL CONTRACT NO: 3215

				
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posted:3/23/2011
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