Pre-Authorized Payment

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Date

{{date}}

PRE-AUTHORIZED PAYMENT AUTHORIZATION

I, the undersigned, {{customer_name}}, residing at {{customer_address}}, and holding identity number {{customer_id_number}}, hereby authorize {{company_name}} (hereinafter referred to as "the Company") to debit my bank account detailed below, for the payment of {{purpose_of_payment}}.

Bank Account Details

Bank Name: {{bank_name}}

Account Holder Name: {{account_holder_name}}

Account Number: {{account_number}}

Branch Code: {{branch_code}}

Account Type: {{account_type}} (e.g., Cheque, Savings, Transmission)

Payment Details

Amount: {{currency}} {{amount}}

Frequency: {{payment_frequency}} (e.g., monthly, quarterly, annually)

Payment Due Date: {{start_date}} (or nearest business day thereafter)

This authorization will remain in effect until cancelled in writing by me, with a minimum of {{notice_period_days}} days' notice prior to the next scheduled payment date. Payments will be debited on the {{day_of_month}} of each {{payment_frequency}}.

Declaration and Undertaking

I understand that the amounts to be debited from my account will be in terms of my agreement with the Company for the {{purpose_of_payment}}.

I acknowledge that all such withdrawals from my bank account by the Company will be treated as if they had been signed by me personally.

I agree to ensure that there are sufficient funds in my account to meet the payments on the due date.

Should there be insufficient funds in my account, I understand that my bank may charge me a fee, and the Company may also charge a penalty fee of {{currency}} {{penalty_fee_amount}} for each dishonoured payment.

I understand that if any deduction date falls on a weekend or public holiday, the deduction will be made on the next business day.

I confirm that I am the authorised signatory on the above-mentioned bank account.

Cancellation of Authorization

I understand that I may cancel this authorization by giving the Company written notice of {{notice_period_days}} business days before the next debit date. I acknowledge that the cancellation of this authorization does not cancel any existing agreement between myself and the Company regarding the {{purpose_of_payment}}.

Amendments

Any changes to the amount or frequency of payments will be communicated to me in writing by the Company at least {{notification_days}} days in advance of the effective date of such change.

Enquiries

All enquiries regarding this authorization should be directed to {{company_name}} at {{company_phone_number}} or {{company_email_address}}.

Signature

_____________________________

Customer Signature

Date: {{signature_date}}

For Official Use Only

Authorised by: _____________________________

Name: {{company_representative_name}}

Position: {{company_representative_position}}

Date: {{authorization_date}}