cputT ACKNOWLEDGEMENT OF Beene student Number: [ | Initials & Surname: - ACKNOWLEDGEMENT OF DEBT AND CONSENT: + thereby acknowledge that | am legally indebted to the Cape Peninsula University of Technology for the total amount of R + Lagree, that should I default to pay off with instalments or settle the outstanding debt as set out herein; the University shall have the right to make this agreement an order of the court without having to notify me first + comprehend fully that any debit order instalment dates will be aligned to my salary date + further acknowledge that the arrangement to pay the above mentioned amount only serves to facilitate my commitment to settle the outstanding debt within the prescribed period set. This does not include the release of results/academic transcripts, certificates or guarantees any future registration unless the account is paid in full ‘+ IWe the undersigned, hereby give my/our consent for the processing (use) and storage of my/our personal information by the university for the purpose of conducting the financial processes. I/We also hereby consent ‘that my/our information may be transferred to any third party assisting the university in carrying out the mentioned process, Full Name & Surname of Account Payer: Contact Number (Office Hours): Cell Phone Number: E-mail Address (Account Payer): _ Cell Phone Number (Student): E-mail Address (Student) _ Signed at _ a Bradeats Sigsatre Ginatare of acount Payer | Please attached the following supporting documents: ] {0 Copy of Student & Bank Account hol 3 Months bank statemen ou FOR OFFICE USE a ‘Academic Assessment: Subjects Registered | [Subject Passed Progressing (YES/NO): | Financial Clearance: Block Removed | YES NOL] Date Removed Removed By: Trane aaron ~ Signature: = SECONDARY APPROVAL ~ DIRECTOR: FINANCIAL OPERATIONS Bat — fora arenaAUTHORITY AND MANDATE FOR PAYMENT, Benetcary Heme: | wi8i CPUT | Bonetrys Actress: | lt owe Suden Gente Syony Way Gabvie Compa] Abrevated name a wil spear on yourbank account: | RECPUT ~——| r HOLDER DETAILS {10 Number Passport number / Temporary Residence Cc NX eae ls to sett tho account behave the sted ———= “BANKING DETAR Zine] | Bank Name] - [ranch cod [Account Number: | [account Type: [—] Gurent (Cheque) lswins LT Trmisson == — COLLECTION DATE DETAILS as == ‘Debit Sequence Type: | —] Recurring [J Once-of «| Collection Day (ie, Day 26) ‘Date From (same as salary date: Date To | [ Date Adjustment Rue 7 Frequency (select the applicable} - i Wnty by Rule woekty []rornitty [ [monty [J avsrerty [| annoaty [J] sinnuany | Monthy wana TPE E — instalment Amount: Maximum Amount: umber of instalments: 7] Fixed Mandate [variable Mandate [Usage Based Mandate I “Adjustment Category: ‘Annually [J Biannually ‘Quarterly [__] Repo [eT Never Specify Adjustment Amount7 Rate % [NA — First Coocton Date it required) Fiat Collection Amount if required Te, an amount - l that Is not the same as the instalment amount) “Th signed AOA and Mandate refers OF eonact Ty here ae sufciontYunds nthe (my) nomad accountTG meet dated, ("the Agreement") the obligation, you are entitled to track my account and re-present the instucton er payment as soon a suicent funds ae avaabe LWehereby aunorise you to esue and deliver payment insituctions to your Banker for collection against my/our (We acknowledge that al payment instructions issued by you shall be ‘abovernentioned account on candition thatthe sum of such payment | treated by my/our above mentioned Bank as the instructions hac been instructions wil never exceed mylour obligations as agreed to in the | issued by melus personally ‘Agreement and commencing on and continuing untl his Authority and Mandate i Torminated by metus. We agree that athough this Authority and Mandate may be cancelles ‘by metus, such cancelation wil not cancel the Agreement. Ie shal ‘The individual payment instructions so authorised to be Issued must be | not be entitled to any refund of amounts which you have whan 'ssued and delivered as follows ‘While this Authority was in force, such amounts were legally owing t2 you. on or after the dates when the obligation in terms of the Agreement is {ue and the amount ofeach individual payment instruction may not be | We acknowledge that this authority may be ceded or assigned to ‘more or less than the obligation due third party the Agreement is also ceded or assigned to that thd pals but inthe absence of such assignment cf the Agieement. hss Authoe's 1) In tho event thatthe payment day falls on a Sunday or recognized | and Mandate cannot be assigned ay tid port public holiday, the payment day wll automatically be the very next otdinary business day, TERMS AND CONDITIONS: ‘+ With even! that my salary or my banking details changes, Mis my O=PONSHIy to nfm tho Unser sty in wing 3nd prow the New nk understand that shou ace any taneayitonn wun the dea my payne the User's Sent Acces Oeice Cw Sy cancel teinate the agrooment when the accounts aly pad + Al changes and aerators must bu signe or autionz04 by the payer And Yo ba sunt oto ravant consultant assign to hay 35 1 Fureames, consent tho eats hes on me to eee ae NB: Please be advised that al amendments & cancellation requests must be sont in writing within 10 business days prir tothe N deduction date, * 2 ™ lsputediRaversed payne ~~ _ Mi DieputedRaversed payments willbe charged an amount of R20.00 pe ned at