The reference number on the bank statement will always start with MULTID FOR SFEET plus your unique reference number.
Payment instruction
(Specify where applicable)
Specific Collection Period *
Specific Collection Period
From Month
To Month
Amount Allowed *
Account holder details
Name *
Company/Closed Corporation/Trust/Deceased Estate/Partnership/Other Legal Person
Language *
Physical Address
Physical Address
Telephone Number | Home
Telephone Number | Home
Telephone Number | Work
Telephone Number | Work
Telephone Number | Mobile
Telephone Number | Mobile
Bank Details
Type of account *
Date of first deduction *
Date of first deduction
Thereafter regularly according to the agreement
* if applicable | except for payment instructions due in December which may be debited against my account on
If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday); I agree that the payment instruction may be debited against my account on the following business day. *
Any payments in arrears must be collected additionally with the first deduction?
I, the undersigned, request SAMARITAN FEET SA to arrange with my bank to collect, by means of the debit order system, the payments in terms of the stipulations of the contract and payments in arrears (as they may be amended from time to time/where applicable/where so requested) of the above-mentioned against my account.
Date *