ACCOUNT HOLDER (DEBTOR) INFORMATION:

ID Number*

Name*

First Last

Email*

Address*

Street Address ZIP / Postal Code

Home Phone

Work Phone:*

Account Holder Name:*

Bank:*

Branch Code*

Account Number:*

Account Type:*

Current
Savings
Transmission
Other

Collection Instructions

Interval*

Once Off
Monthly

Is this limited to fixed amounts, or to debits due in future that may vary?

Amount*

Fixed Amount
Variable Amounts

Note: If variable, the amount(s) hereunder may be exceeded.

Once off transaction: Collection date:

Amount

Recurring transactions: Continue Indefinitely Untill Cancelled by debtor?

Yes
No

1st Collection date:

Amount

Day of Month thereafter:

Number of Deductions

Final debit date

I

the above mentioned and undersigned, hereby authorize XCHNGE to collect by debit order from the above mentioned bank account, all amounts due in terms hereof to be debited as the above.

I

is the person with signature authority as registered with my bank to authorized electronically.

Confirm Debit Date

The abbreviated name that will appear on bank statement will appear as Xchnge

Confirm Phone Number*

Enter The Above Validated OTP Number:*

Date Generated

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Debit Order Form

Debit Order Form

Step 1 of 2

ACCOUNT HOLDER (DEBTOR) INFORMATION:

Collection Instructions

Agreement